Ebook Family practice guidelines (4/E): Part 2

Part 2 book “Family practice guidelines” has contents: Gynecologic guidelines, sexually transmitted infections guidelines, infectious disease guidelines, systemic disorders guidelines, musculoskeletal guidelines, rheumatological guidelines, psychiatric guidelines, neurologic guidelines,… and other contents.

A Primary amenorrhea

1 No menstrual period by age 14  years in the absence of growth or development of secondary sex-ual characteristics

2 No menstrual period by age 16 years regardless of

the presence of normal growth and development with the appearance of secondary sexual characteristics

B Secondary amenorrhea: No menstrual period for

6 months in a woman who usually has normal periods,

or for a length of time equal to three- cycle intervals in a woman with less- frequent cycles

Incidence

A Amenorrhea in a woman who has had menstrual

peri-ods is quite common at some time during her reproductive life Amenorrhea that is a result of agenesis of part of the reproductive system or a chromosomal anomaly is quite rare See the following for the incidence of each cause

Pathogenesis

A Physiological: Pregnancy, breastfeeding, and menopause

B Disorders of the central nervous system lamic): Hypothalamic amenorrhea is the most common cause of amenorrhea (28%) Th ere is a defi ciency in pulsa-tile secretion of gonadotropin- releasing hormone (Gn- RH)

(hypotha-Examples include a stressful lifestyle (10%); weight loss as

in anorexia or bulimia (10%); extreme exercise; tions, such as hormones, as in postpill amenorrhea; hypo-thyroidism (10%); and major medical disease such as Crohn’s disease or systemic lupus erythematosus (SLE)

C Disorders of the outfl ow tract or uterine target organ:

Abnormalities in the systems of this compartment are uncommon Examples include Asherman’s syndrome from inadvertent endometrial ablation during dilation and curettage (D&C; causes 7% of amenorrhea); and agenesis

or structural anomalies of the uterus, tubes, or vagina

D Disorders of the ovary:  Examples include abnormal

chromosomes such as Turner’s syndrome (0.5%); mal chromosomes (10%) such as in gonadal dysgenesis or agenesis (there may be no or very delayed Tanner stage);

nor-premature ovarian failure (POF); nor-premature menopause, before the age of 40 years; eff ect of radiation or chemo-therapy; and polycystic ovarian (PCO) disease

E Disorders of the anterior pituitary: Examples include

A “I haven’t had a period in months.” “I have periods

only a few times each year.”

B “I have nipple discharge.”

C “I am 16  years old and have never had a menstrual

period.”

Other Signs and Symptoms

A Irregular, infrequent menstrual periods

B Galactorrhea

C Pregnancy

D Excessive hair growth

Subjective Data

A Review complete menstrual history, including age of

onset, duration, frequency, regularity, and dysmenorrhea

B Review the patient’s pregnancy history

C Review the patient’s contraception history

D Note other medications the patient is taking, such as

hormones or antidepressants

E Ask the patient if she has had a major medical disease

or treatment such as chemotherapy for a childhood cancer

F Inquire about any breast discharge

G Review the patient’s weight pattern

H Ask the patient to describe her physical self- image

Does she consider herself obese or fat?

I Review sources of stress in her life

J Discuss exercise pattern and history

Physical Examination

A Check height, weight, blood pressure (BP), and pulse

B Inspect

1 Note overall appearance Look at the neck

(thy-roid) Inspect the breast/ genitalia for Tanner staging

See Appendix C: Tanner’s Sexual Maturity Stages

2 Skin assessment:  Check for central hair growth,

which is androgen- responsive Areas to inspect for

1 Th e neck for thyroid enlargement

2 Th e abdomen for enlarged organs or uterine enlargement compatible with pregnancy

D Auscultate

1 Auscultate the heart and lungs

2 If pregnancy is suspected, consider auscultating for

fetal heart tones

E Pelvic examination

1 Inspect external genitalia Note pubic hair

pat-tern for Tanner staging Note any lesions, masses, or discharge

2 Speculum examination:  Inspect vagina and

cer-vix Note bluish color, which is Chadwick’s sign with pregnancy

3 Bimanual examination: Palpate for softening of the

cervical isthmus, which is Hegar’s sign for pregnancy

Palpate for size of uterus and for adnexal masses

Diagnostic Tests

A Urine: Pregnancy test

B Serum

1 Serum human chorionic gonadotropin (HCG)

2 Th yroid- stimulating hormone (TSH) to rule out thyroid disease

3 Prolactin: Normal less than 20 ng/ mL

4 Follicle- stimulating hormone (FSH): Greater than

40 IU/ mL indicates ovarian failure

5 Luteinizing hormone (LH): FSH ratio to rule out

polycystic ovaries

C Vaginal and/ or pelvic ultrasonography

D Genetic testing/ karotype analysis in primary

E Polycystic ovary syndrome (PCOS)

F POF, or early menopause

1 If laboratory values are normal, proceed to

pro-gesterone challenge test to rule out hypothalamic amenorrhea

2 If the patient is pregnant, counsel regarding

preg-nancy and begin antepartum care

3 If other laboratory information points to an

under-lying cause for amenorrhea, treat as appropriate

B Patient teaching: See Section III: Patient Teaching

Guide for this chapter, “Amenorrhea.”

C Pharmaceutical therapy

1 Progesterone challenge

a Micronized progesterone (Prometrium) 300 mg

daily or medroxyprogesterone acetate (Provera) 10 mg each day for 5 days

b Positive test is any vaginal bleeding Withdrawal

bleeding should occur within 7 to 10  days after

fi nishing the medicine A late vaginal bleed may be associated with ovulation

c In the absence of galactorrhea, with a normal

prolactin level, normal TSH, and positive terone challenge, further evaluation is unnecessary

proges-All anovulatory patients require therapeutic agement Th ere is a risk of endometrial cancer with unopposed estrogen Th ere is a short latent period in progression from a normal endometrium to atypia to cancer, even in a young woman

A negative withdrawal bleed may be associated with PCOS

2 Progesterone therapy for hypothalamic amenorrhea

a Medroxyprogesterone acetate (Provera, Cycrin)

10 mg for 10 days each month

b Low- dose oral contraceptive pills

c Clomiphene citrate for women desiring pregnancy

perimenopausal women Follow- Up

A Reproductive age:  Th e patient should return after

6  months of treatment with progesterone or oral traceptive pills Discontinue the hormones and assess for return of normal periods If this does not occur, reinsti-tute progesterone or oral contraceptive therapy

B Perimenopausal:  Maintain hormonal therapy Th e patient should return annually

Consultation/ Referral

A Refer the patient to a physician if there is no

problem is either with the outfl ow track, which is rare, or with the ovarian production of estrogen or hypothalamic production of gonadotropins Th is is usually beyond the scope of the nurse practitioner

B Refer the patient to a physician if her prolactin level is

elevated (greater than 20 mg/ mL) for further workup to rule out pituitary adenoma

Individual Considerations

A Adolescence

1 Rule out pregnancy Th en determine whether mary or secondary amenorrhea Refer the patient to a physician for primary amenorrhea

2 For secondary amenorrhea, complete assessment

and evaluation Assess stress/ emotional status, tional status, and exercise routine

3 Refer to a physician if there is no withdrawal

bleed-ing from progesterone challenge test

▶

Atrophic V

4 Refer for evaluation and treatment as indicated for

eating, exercise, or psychiatric disorders

B Older adults

1 Irregular menses and amenorrhea are common during perimenopause Provide anticipatory guidance and instructions regarding the need for contraceptive use until menopause is confi rmed

Atrophic Vaginitis

Rhonda Arthur

Defi nition

A Atrophic vaginitis is infl ammation of the vaginal

epi-thelium due to a lack of estrogen support Anything that lowers estrogen levels after puberty can result in a loss of vaginal thickness and rugosity and a decrease in the elas-ticity of the vaginal tissues

Incidence

A Atrophic vaginitis is very common It may occur

in three stages of a woman’s life:  Preadolescence, when breastfeeding a baby, and postmenopause

Pathogenesis

A Estrogen maintains the vaginal pH in an acidic range

Lack of suffi cient estrogen promotes an increase in vaginal

pH that supports the development of bacterial infections

Estrogen loss also results in a decrease in vaginal glycogen and a thin- walled epithelium, promoting friability and infl ammation

B Is this a new problem? If so, review the use of a new

soap, laundry detergent, or hygiene products

C Describe the color, amount, and odor of vaginal

dis-charge or bleeding

D Determine existence of coexisting vasomotor

symp-toms, such as hot fl ashes

E Is the patient experiencing dysuria, urinary frequency,

vulvar dryness and itching, or dyspareunia? With reunia, question the patient whether the discomfort is due to irritation or pain with deep penetration, or both

F Determine whether the patient is breastfeeding and

for what length of time

G Ask the patient the date of her last menses and if

she is having irregular cycles Determine whether the patient had a hysterectomy with oophorectomy or ovar-ian failure

H Review the number of the patient’s sexual partners

and any new sexual practices

I Review the patient’s current medications, including

antidepressants

J Explore whether she has stopped hormone

replace-ment therapy (HRT)

K Has the patient tried any self- help measures? Was

there any relief?

L When was the last Papanicolaou (Pap) smear, and

what were the results?

Physical Examination

A Check temperature, pulse, and respirations

B Inspect: Observe the patient generally for discomfort

before, during, and after examination

1 Examine external genitalia for friability, erythema,

lesions, condyloma, and amount and color of discharge

2 Sparse and brittle pubic hair, shrinking of the labia

minora, and infl ammation of the vulva may be noted

1 Check rugae, friability of vaginal epithelium, and

color and amount of discharge; evaluate cervix for lesions, friability, and erythema

2 Typical atrophic symptoms on inspection:  Th in, friable vaginal epithelium; decreased or absent vaginal rugae; scant vaginal discharge

A Routine hormone measurements to evaluate

meno-pause status are not routinely indicated

14 Gynecologic

B Urine culture, if applicable

women is 4 to 4.5 Reduced levels of estrogen increase

vaginal pH

D Pap smear with maturation index (Vaginal wall

mat-uration index evaluation is controversial.)

E Wet prep, if applicable

1 Multiple white blood cells (WBCs) indicate infl ammation, may show increased bacteria, and may have decreased lactobacillus, suggesting atrophic vaginitis

2 Test should be negative for Trichomonas Bacterial

vaginosis (BV): Whiff test should be negative

F Cultures for gonorrhea and chlamydia, if applicable

G Ultrasound for uterine lining thickness if applicable

(less than 4 or 5 mm suggests loss of estrogenic stimulation)

H Endometrial biopsy, if indicated.

Postmenopausal vaginal bleeding must be thoroughly investigated to rule out the possibility of endometrial hyperplasia or endometrial cancer

Differential Diagnoses

A Atrophic vaginitis

B Trauma

C Foreign body in the vagina

D Urinary tract infection (UTI)

E Vaginitis from infective cause:  Fungus, bacteria,

1 Treat any underlying infections (gonorrhea,

chla-mydia, vaginitis, as diagnosed)

B Patient teaching

1 See Section III: Patient Teaching Guides for this

chapter, “Atrophic Vaginitis” and “Dyspareunia (Pain With Intercourse).”

2 Preadolescent girls have amelioration of toms with increase of endogenous estrogen as puberty approaches

3 Women should be reassured that this problem is

physical, not emotional

4 Discuss the benefi ts of regular sexual activity to

decrease problems of atrophic vaginitis An tant reason for decreased sexual activity is unavail-ability of a partner Masturbation also facilitates the natural resumption of the production of lubricating secretions by the body Decline in sexuality is infl u-enced by culture and attitudes as well as physical problems

5 Symptomatic relief of dryness during sexual

activ-ity may be obtained with the use of water- soluble lubricants and adequate foreplay

6 Vaginal moisturizer may be applied for relief of

symptoms

7 Discuss pregnancy prevention and inform that

per-imenopausal symptoms do not ensure lack of fertility

C Pharmaceutical therapy

1 Calamine lotion may be applied externally for local symptomatic relief

2 Estrogen therapy (ET)

a Vaginal hormonal therapy

Absolute contraindications for use of ET also apply to use of topical estrogen (breast cancer, active liver dis- ease, history of recent thromboembolic event) Vaginal estrogen creams are systemically absorbed As with use

of oral and transdermal estrogen, a progestin must be administered to women who have an intact uterus, sec- ondary to the risk of endometrial hyperplasia or cancer

i Conjugated estrogen (Premarin) cream 0.625 mg/ g: Use 0.5- to 1.0- g applicator inserted intravaginally at bedtime every night for 1 to 2 weeks, then every other night for 1

to 2 weeks, then as needed Not for daily use if the patient has an intact uterus

ii Estradiol (Estrace) 0.1 mg/ g: Use one

half (2 g) to one (4 g) applicator inserted intravaginally at bedtime every night for 1 to

2 weeks When vaginal mucosa is restored, maintenance dose is one- quarter applicator (1 g) one to three times weekly in a cyclic regimen Not for daily use if the patient has

an intact uterus

Vaginal estrogen creams should not be used as a cant before intercourse as the hormone can be absorbed through a partner’s skin

Vaginal estrogen creams are systemically absorbed

As with use of oral and transdermal estrogen, a gestin must be administered to women who have an intact uterus, secondary to the risk of endometrial hyperplasia or cancer

iii Estradiol (Estring) 7.5 mcg/ 24 hr; insert

one ring in vagina and replace every 90 days

iv Estradiol hemihydrate (Vagifem) vaginal

tablets 25 mg; insert: One tablet in vagina each day for 14 days, then one tablet twice weekly for 10 weeks

b Oral estrogen replacement therapy

i Conjugated estrogen (Premarin) 0.625 mg orally every day from day 1 through 25, of a month plus conjugated estrogen (Provera) 10 mg orally on days 13 through 25

ii See “Menopause” section for other

regi-mens of hormone replacement therapy (HRT)

For long- term ET, consider use of oral or patch ods of delivery if the patient shows additional symp- toms of hypoestrogenemia (i.e., hot fl ashes, night sweats)

meth-▶

Bacterial V

Follow- Up

A Breastfeeding women should be reevaluated following

weaning, especially if symptoms persist (i.e., alternate ology is suspected)

B Postmenopausal women should be evaluated for

addi-tional etiologies (i.e., endometrial hyperplasia) if nal bleeding persists beyond 3 to 6  months following a treatment

C Th e patient should return to clinic 1 to 2 months after beginning oral or vaginal drug therapy; the patient then needs to be seen in 3 to 6 months to check side eff ects, blood pressure (BP), and response to therapy

D Perform Pap smears and physical examination per

patient health history or risks and guidelines

Consultation/ Referral

A If bleeding is a symptom in a postmenopausal woman,

the practitioner must rule out bleeding of uterine origin

If there is any doubt, consultation for endometrial biopsy

or dilation and curettage (D&C) must be obtained

Individual Considerations

A Breastfeeding women

1 Breastfeeding women have amelioration of

symp-toms as weaning progresses unless an alternate ogy exists

B Postmenopausal women

1 Evaluate the patient for other risks of

hypoestro-genemia, such as cardiovascular disease and porosis Continuous systemic estrogen replacement therapy may be indicated

2 Vaginitis in the postmenopausal woman is rarely

due to any of the organisms responsible for tis in the premenopausal woman (unless she has new sexual partners) Candidiasis, trichomoniasis, and BV are uncommon after the menstruating years

Bacterial Vaginosis (or Gardnerella)

Rhonda Arthur

Defi nition

A Bacterial vaginosis (BV) is an infection of the vagina

caused by an alteration in the normal fl ora of the vagina, with an increase in anaerobes and gram- negative bacilli as well as a decrease in the Lactobacillus  fl ora

Incidence

A BV is one of the most common vaginal infections in

women of childbearing age and is common in pregnant women It is not considered exclusively a sexually trans-mitted infection (STI)

Pathogenesis

A Th e main etiologic agent in BV is an increase in anaerobes in the vagina Th e reason why this occurs is unknown, but is associated with having multiple sex-ual partners, douching, lack of condom use, and lack of vaginal lactobacilli When the normal lactobacilli of the vagina decrease, the vaginal pH is increased Th e organ-isms present in BV cause the level of vaginal amines to

increased, causing the characteristic “fi shy” odor

B Bacterial vaginitis is primarily polymicrobial, and the

pathogens seen include Bacteroides species, Peptostreptococcus

Gardnerella , and Mycoplasma hominis Th e incubation period is unknown

Predisposing Factors

A History of STIs

B Multiple sexual partners

C Intrauterine device (IUD) use

D Factors that change the normal vaginal fl ora

1 Hormonal changes (menses, pregnancy)

2 Medications: Oral contraceptive use and antibiotic

therapy

3 Foreign bodies in the vagina (tampons, IUDs),

semen, and douching

B Increase in odor after menses

C Occasional itching and burning

Subjective Data

A Elicit onset, duration, and course of presenting symptoms

B Review any changes in the characteristics and color of

vaginal discharge Does the patient’s partner(s) have any symptoms?

C Review any symptoms of pruritus, perineal

excoria-tion, burning; signs of urinary tract infection (UTI)

D Review medication and medical history

E Determine whether the patient is pregnant; note the

date of last menstrual period (LMP)

F Question the patient for a history of STIs or other

vaginal infections

G Review previous infection, treatment, compliance with treatment, and results

H Note the last intercourse date

I Elicit information about possible foreign body

J Review use of vaginal deodorants or sprays, scented

toilet paper, tampons, pads, and douching habits

K Review change in laundry detergent, soaps, and fabric

softeners

L Review use of tight restrictive clothing, tight jeans,

and nylon panties

therapy

Physical Examination

A Check temperature, pulse, and respirations

B Inspect: Examine external vulva and introitus for

dis-charge, irritation, fi ssures, lesions, rashes, and condyloma

14 Gynecologic

C Palpate

1 Palpate the abdomen for masses or tenderness

Note enlarged or tender inguinal lymph nodes

2 Palpate the external perineal area for vulvar masses

3 “Milk” the urethra for discharge

4 Check for costovertebral angle (CVA) tenderness

D Pelvic examination

1 Inspect

a Note the color, amount, and odor of discharge

b Inspect the cervix

i BV is a vaginosis rather than a vaginitis

Th ere is usually little or no infl ammation of the vaginal epithelium associated with BV

ii BV is associated with a pink, healthy

cer-vix; “strawberry cervix” is seen with cervicitis due to Trichomonas vaginalis

iii A red, edematous, friable cervix is seen

with Chlamydia trachomatis

2 Speculum examination

a Inspect sidewalls for adhering discharge

b Th e clinical diagnosis of BV requires the ence of three of the following four signs:

i Homogeneous, white, adherent vaginal discharge may be present

ii Vaginal fl uid pH greater than 4.5 For

accurate pH, take smear for testing from the lateral walls of the vagina, not from the cervix

iii A fi shy, amine- like odor from vaginal

fl uid before or after mixing it with 10% sium hydroxide (positive whiff test) Semen releases the vaginal amines; therefore, there is

potas-an increase in odor after intercourse

iv Presence of “clue cells” (squamous vaginal

epithelial cells covered with bacteria, causing

a stippled or granular appearance and ragged,

“moth- eaten” borders) or coccobacilli forms both

in the fl uid and adheres to the epithelial cells

3 Bimanual examination: Check for cervical motion

tenderness (CMT) and adnexal masses BV may be a risk factor for pelvic infl ammatory disease (PID)

Diagnostic Tests

A Gram stain (considered the gold standard)

B BV can be diagnosed by use of clinical criteria; three

of the following four are needed to make clinical

diagno-sis (Amsel’s diagnostic criteria [DC]):

1 Vaginal pH: Greater than 4.5 with BV; normal

vaginal pH range is 4 to 4.5

2 Clue cells on microscopic examination

3 Homogeneous, thick white discharge that coats

the vaginal walls

4 A fi shy odor of the vaginal discharge before or after

the addition of 10% KOH (wet prep with 10% sium hydroxide and normal saline prep); microscopic examination of vaginal secretions should always be done

C Herpes culture, if indicated

D Urinalysis and culture, if indicated

1 Inform the patient regarding other

following:

a Vinegar and water douches: One tablespoon of

white vinegar in 1 pint of water Douche one to two times a week

b Lactobacillus acidophilus culture; four to six

tab-lets by mouth daily

c Garlic suppositories: One peeled clove of

gar-lic wrapped in a cloth dipped in olive oil inserted vaginally overnight and changed daily

B Patient teaching

1 See Section III: Patient Teaching Guides for this

chapter, “Bacterial Vaginosis.”

2 BV is not considered an STI

C Pharmaceutical therapy

1 Drug of choice

a Metronidazole (Flagyl) 500 mg orally twice daily for 7 days or

b Metronidazole gel 0.75% one applicator (5 g)

vaginally at bedtime for 5 days

i Metronidazole is less expensive, easier to

use, and associated with greater compliance

ii Side eff ects of metronidazole include

sharp, unpleasant metallic taste in the mouth; furry tongue; central nervous sys-tem (CNS) reactions, including seizures; and urinary tract disturbances Advise patients

to avoid alcohol while taking metronidazole and 24 hours after completing the medica-tion, or they will experience the severe side eff ects of abdominal distress, nausea, vomit-ing, and headache

iii Metronidazole may prolong prothrombin

time in patients taking oral anticoagulants

2 Other medications if the patient is unable to use

oral metronidazole

a Clindamycin 300 mg by mouth twice daily for

7 days

applicator vaginally twice daily for 5 days

c Clindamycin 2% cream one applicator

vagi-nally at bedtime for 7 days

Clindamycin cream is oil based and may weaken latex condoms for at least 72 hours after terminating therapy

▶

a Metronidazole 500 mg orally twice a day for

7 days or 0.75% metronidazole gel 5 g vaginally once daily for 5 days

b Clindamycin 300 mg orally twice a day for 7 days

Follow- Up

A Nonpregnant women: No follow- up is recommended

unless indicated Recurrence is common

B Pregnancy: High risk for preterm delivery; pregnant

women should be reevaluated 1 month after treatment

C Immunocompromised women: Recommendations

for treatment of BV in females infected with HIV are the same as for noninfected patients

D Partners: Consider treatment of the patient’s partner(s)

in women with recurrent disease

increased adverse events in newborns and should not

be used during the second half of pregnancy

B Partners

1 Routine treatment of a patient’s partner(s) is not

recommended at this time because it does not infl ence relapse or recurrence rates

Bartholin’s Cyst or Abscess

Rhonda Arthur

Defi nition

A Th e Bartholin’s glands are small, round, nonpalpable mucus- secreting organs Th ey are located bilaterally in the posterolateral vaginal orifi ce Obstruction of the duct causes the gland to swell with mucus and form a Bartholin’s cyst Th e cause of obstruction is usually unknown but may

be due to mechanical trauma, thickened mucus, plasm, stenosis of the duct, or infectious organisms not limited to sexually transmitted infections (STIs) Th e cyst may become infected, resulting in an abscess Cysts develop more commonly in younger women, and occur-rence decreases with aging; therefore, it is important to rule out neoplasm in women older than 40 years experiencing Bartholin’s cyst

B Th e majority of women with Bartholin’s cyst are asymptomatic, but large cysts can cause pressure and interfere with walking and sexual intercourse Abscesses generally develop rapidly over a 2- to 3- day period and are painful Some abscesses may spontaneously rupture and often reoccur

B Review any changes in the characteristics and color of

vaginal discharge Does the patient’s partner(s) have any symptoms?

C Review any symptoms of pruritus, perineal

excoria-tion, burning; signs of urinary tract infection (UTI)

D Review the patient’s medication and medical history

E Determine whether the patient is pregnant; note the

date of last menstrual period (LMP)

F Question the patient for a history of STIs or other

1 Examine external vulva and introitus for discharge,

irritation, fi ssures, lesions, and rashes Bartholin’s cyst will appear as a round mass usually near the vaginal orifi ce causing vulvar asymmetry

A Culture and sensitivity of purulent abscess fl uid

B Cervical culture for STI ( Neisseria gonorrhoeae and

1 Reassurance is indicated for women younger than

40 years with asymptomatic cysts Incision and age (I&D) is often required for symptomatic cysts and abscesses Because cysts and abscesses often reoccur,

drain-14 Gynecologic

surgery to create a permanent opening from the duct

to the exterior is often the defi nitive treatment Two such surgical methods are placement of a Word cathe-ter or marsupialization Referral is indicated for I&D and other surgical interventions if the provider is not experienced with the procedures

Women older than 40 years must be referred for cal exploration and excision biopsy

B Patient teaching

1 Reassure women younger than 40  years that asymptomatic cysts do not need intervention Rapidly enlarging cysts that are painful or obstruct the vaginal orifi ce need to be reevaluated

2 Warm sitz baths three or four times a day may

encourage spontaneous rupture of abscess and vide comfort

C Pharmaceutical therapy

1 Abscesses are treated with an antibiotic that

cov-ers methicillin- resistant Staphylococcus aureus (MRSA)

such as trimethoprim 160/ sulfamethazone 800 mg twice a day or amoxicillin/ clavulanate 875 mg bid for

7 days plus clindamycin 300 mg orally four times a day for 7 days

B Pregnancy: Treatment with antibiotics is

recom-mended due to the risk of complicated infection Avoid

preg-nancy Refer to obstetrics and gynecology (OB/ GYN) for

recurrence

Breast Pain

Rhonda Arthur

Defi nition

A Benign breast disorders such as mastalgia,

masto-dynia, and fi brocystic breast changes are characterized by

lumps or pain Th e lumps may be a physiological

nod-ularity, a ropy thickening, or distended fl uid- fi lled cysts

that are mobile Th e pain may be cyclic or noncyclic, and

it may be unilateral or bilateral

Incidence

A Th is is a very common problem Fifty percent or

more of menstruating women experience breast pain

Two thirds of breast pain is cyclic and occurs in women

in their 30s; one third is noncyclic and may occur in women at any age, but it tends to occur in women closer

to menopause

Pathogenesis

A Dysplastic, benign histologic changes occur in the

breast such as hyperplasia of the breast epithelium, sis microcysts and macrocysts, duct ectasia, and apocrine metaplasia

Predisposing Factors

A Menstruation (related to hormonal changes)

B Certain medications [combination oral tives (COCs), hormone therapy, antidepressents, and others]

C Ingesting substances containing methylxanthines

(coff ee, tea, chocolate, and cola drinks) Methylxanthines have been noted to contribute to breast pain by clinical observation only

D Pregnancy

Common Complaints

A “My breasts are painful, particularly just before my

period.”

B “I have lumps in my breasts, and they hurt.”

Other Signs and Symptoms

A Tender breasts with palpation

B Ropelike masses, usually bilateral, with mobile, well-

circumscribed masses that are cystic or rubbery

Subjective Data

A Elicit history of pain Note onset, duration, location,

and relation to menstrual period Ask: Is pain constant or intermittent?

B What has the patient tried to alleviate the pain? Note

what has worked, such as nonsteroidal anti- infl ammatory drugs (NSAIDs)

C Note the patient’s family history of breast pain, lumps,

or cancer

D Has there been trauma such as being hit or having a

rough experience during sex?

E Do her breasts hurt during or after exercise such as

running, aerobics, soccer, or basketball?

F Does she wear a good, supportive, properly fi tted bra

generally and for sports?

G Has she had any breast surgery or biopsy?

H Note medication history such as oral contraceptives

Physical Examination

A Inspect

1 Examine the breasts, and note masses; dimples;

changes in the skin; changes in the way the nipples are pointed while the patient is in the sitting position with arms in neutral position in lap, above the head,

or pressing in on hips

B Palpate

1 Th e breasts; look for hard, fi xed, or cystic masses

in the breast, under the nipple, in the tail of the

Breast Pain

breast, and in the axilla Use a standardized breast examination technique Compress the nipple for discharge Measure masses, and describe them in the patient’s record Use a clock face to describe their location

C MRI is useful for detecting tissues with increased

blood fl ow but limited by false-positive results

D Fine- needle aspiration and biopsy

E Excisional biopsy for solid lumps

F Pregnancy test (as indicated)

Differential Diagnoses

A Fibrocystic breast changes with mastalgia

ectasia

C Nipple discharge:  Duct ectasia, prolactin- secreting

pituitary tumors

D Pain: Costal chondritis, chest wall muscle pain,

neu-ralgia, herpes zoster infection, and fi bromyalgia

1 Reassure the patient Use the term fi brocystic

changes rather than fi brocystic disease to stress the

func-tional nature of the problem Stress that the pain is real but not caused by a disease state

B Patient teaching

1 See Section III: Patient Teaching Guide for this

chap-ter, “Fibrocystic Breast Changes and Breast Pain.”

2 Teach the patient breast self- examination

Encour-age monthly breast self- examination Continue cal breast examinations annually

3 “Lumpiness” that varies with the menstrual cycle

is not abnormal Breasts may normally be of diff erent sizes It is a change that is signifi cant

4 Consider changing the dose or discontinuing

hor-mone replacement therapy (HRT) for women on HRT with mastalgia

5 Symptomatic measures to relieve discomfort

a Good supportive bra, properly fi tted Adolescents

whose breasts are maturing and perimenopausal women whose bodies are changing are two groups who often wear improperly fi tted bras

b Local heat or ice application (whatever works

best)

C Diet

1 Elimination of methylxanthines is a good idea, but

the relationship of methylxanthines to breast pain is unproven in research studies

2 Reduction of dietary fat and sodium intake has

also been advocated, but has not been supported by research

D Pharmaceutical therapy

1 Diuretic: Spironolactone (Aldactone) 10 mg twice

daily premenstrually

2 Oral contraceptive pills:  Low- dose estrogen

(20 mcg) pills are recommended

3 Topical nonsteroidal anti- infl ammatory gel can be

used for local mastalgia

4 Antiestrogen treatment

not inhibit ovulation Th e patient must use a rier contraceptive or intrauterine device (IUD) contraceptive measure Although the side- eff ect profi le is signifi cant, long- term symptomatic relief and histologic changes may be achieved

breast pain

5 Vitamins

a Vitamin E is no longer recommended for

treat-ment of mastalgia

b Research has demonstrated mixed results on

the benefi ts of vitamin B 6 and vitamin A

6 Herbs

a Flaxseed 25 mg daily may have show benefi t in

the treatment of cyclic mastalgia

b Evening primrose oil (EPO):  Th ere is insuffi cient evidence to recommend EPO for the treat-ment of mastalgia

Follow- Up

A Young women with fi brocystic changes need to be

seen after 1 to 2 months of pharmacological therapy to assess for complications and effi cacy

B Women with atypical hyperplasia on biopsy need close follow- up every 3 to 6 months by a physician

Consultation/ Referral

A Consult or refer the patient to a physician when breast

masses are identifi ed

B Consult with a physician and refer the patient to a

surgeon if fi ndings include a suspicious mammographic study, an abnormal needle biopsy, or a solid mass per ultrasonogram

aver-age risk according to the American Cancer Society:

Mammography is off ered annually for women from ages 40 to 64 years, and women should be informed

of the risks, benefi ts, and limitations of regular screening Women aged 45 to 54 years should have

an annual mammogram Women aged 55 years and older should switch to a mammogram every

▶

14 Gynecologic

2 years but be off ered the choice to continue yearly screening

potential risks, benefi ts, and limitations of ing High- risk women may benefi t from additional screening, including earlier initiation of screening and additional screening modalities such as ultra-sound and MRI

3 When clinical breast examination, mammography,

and needle-aspiration biopsy are used, breast cancer detection rates are 93% to 100%

A Cervicitis is acute or chronic infl ammation of the

cer-vix that is visible to the examiner

B Chronic cervicitis is primarily due to the following:

instrumentation

2 Infection (see earlier)

3 Presence of foreign bodies (i.e., intrauterine devices

[IUDs]) Predisposing Factors

Other Signs and Symptoms

A Asymptomatic; may be found on routine gynecologic

A Determine onset, duration, and course of symptoms

Is there any dyspareunia, pelvic pain, fever, or urinary symptoms?

B Determine characteristics of the vaginal discharge

C Review the patient’s history of STIs

D Review the patient’s sexual history to include number

of partners and partner symptoms (if any), use of sex toys, and sexual lifestyle

E Note the last Papanicolaou (Pap) smear and results

Has the patient ever had an abnormal Pap; if so, how was

it treated?

F Note date of last menstrual period (LMP), use of

con-traception, and type(s) of contraception

G If the patient has recently been pregnant, review her

records for cervical cerclage, vaginal delivery with cervical laceration, or other complications

Physical Examination

A Check temperature, pulse, and respirations

B Inspect

1 Observe generally for discomfort before, during,

and after examination

2 Observe the external vulva for Bartholin’s gland

enlargement (Bartholin’s gland abscess is due ily to infection by chlamydia), lesions, irritation, fi s-sures, and condyloma

3 Note color, amount, and odor of vaginal discharge

C Palpate

1 Back: Note CVA tenderness

2 Abdomen: Palpate for enlarged or tender inguinal

lymph nodes

D Pelvic examination

1 Speculum examination:

a Inspect cervix for infl ammation and ectropion

Cervical ectropion is found in 15% to 20% of healthy young women (especially in teens and with the use of oral contraceptives) It represents colum-nar epithelium that is found farther out on the ecto-cervix, causing the cervix to appear granular and red Presence of cervical erosion, however, suggests advanced cervical pathology A “strawberry cervix”

(petechiae) is highly suggestive of T. vaginalis

b Check cervix for friability and bleeding when

the cervix is touched with a cotton- tipped swab

c Assess the vagina and cervix for leukoplakia,

lesions, polyps, and discharge

d Assess vaginal walls for discharge and rugae

e Vesicular or ulcerated cervical lesions warrant

testing for syphilis and/ or chancroid

2 Bimanual examination:

a Check cervical motion tenderness (CMT), adnexal masses, uterine size, consistency, and tenderness

b Milk urethra for discharge

c Palpate Bartholin’s glands

Diagnostic Tests

A White blood cell (WBC), if indicated

B Consider testing for syphilis (rapid plasma reagin [RPR] or Venereal Disease Research Laboratory [VDRL]

test)

C Wet prep

D Cervical cultures for gonorrhea and chlamydia

E Pap smear

F Urine culture and sensitivity, if indicated

G Herpes culture, if indicated

H Urinary tract infection (UTI)

I Cervical ulceration, or erosion, from trauma: Fingernail,

cervical biopsy, postpartum, or sex toys

J Pelvic infl ammatory disease ( PID)

Plan

A General interventions

1 Patients whose culture is negative generally respond to a round of doxycycline therapy, which is the drug of choice for nonchlamydial, nongonorrheal cervicitis

B Patient teaching

1 Women should be encouraged to obtain routine

care and Pap smear evaluations per guidelines

2 Patient should have no sexual intercourse for

1 week and avoid reinfection by abstaining from course until sexual partners are adequately treated

3 Avoid tampons and douches until antibiotics are

completed

4 Give the patient a teaching sheet See Section III:

Patient Teaching Guides for this chapter, “Cervicitis.”

C Pharmaceutical therapy

1 Drug of choice for chlamydia:  Azithromycin 1 g

orally in a single dose or doxycycline 100 mg twice daily for 7 days Treat all partners

2 Drug of choice for gonorrhea:  Ceftriaxone (Rocephin) 250 mg by intramuscular (IM) injection plus either a single dose of azithromycin 1 g orally or doxycycline 100 mg orally twice a day for 7 days

(HSV): Acyclovir 400 mg three times daily for 7 to

10  days for initial outbreak, acyclovir 400 mg three times a day for 5 days for recurrent outbreak or acy-clovir 400 mg twice a day for suppression

4 Drug of choice for trichomonas: Metronidazole 500

mg twice daily for 7 days (treat all partners), or 2 g orally in a single dose Patients should be cautioned

to avoid alcohol consumption during and 24 hours after the completion of oral metronidazole due to a disulfi ram- like reaction (nausea, vomiting, headache, cramps, and fl ushing)

5 Drug of choice for UTI: See the section “Urinary

Tract Infection (Acute Cystitis)” in Chapter 12

Follow- Up

A Recommend “test of cure”:  Return for repeat

test-ing 3  months after treatment because of high rates of reinfection

B Follow up with Pap smear as mandated by guidelines

Consultation/ Referral

A Refer the patient to a physician for suspected

neo-plasm and for cervicitis unresponsive to treatment

B If the cervix has a suspicious lesion, the patient should

be referred for colposcopy and/ or biopsy regardless of cytology results On physical examination, the cervix may

be edematous and erythematous and may show exposed columnar epithelium It may be friable Reddened areas of the cervix may be seen around the cervical os Th e irreg-ularity and friability sometimes diff erentiate them from eversion; other times colposcopy is required to make the distinction

Individual Considerations

A Pregnancy

1 Cervical infl ammation is common in early pregnancy

2 If an STI is diagnosed, nonteratogenic

pharmaco-logical therapies must be implemented

A Contraception is the intentional prevention of

preg-nancy by either or both sexual partners Contraception can be mechanical, chemical, or surgical and is either reversible or nonreversible Considerations in counsel-ing regarding contraceptive choices include cost, effi cacy, safety, and personal considerations such as personal belief systems and ability to use selected method

(CDC) U.S Medical Eligibility Criteria for Contraceptive Use is a formal adaptation of the 1996 World Health Organization’s Medical Eligibility Criteria for Contraceptive Use Th is valuable document assists health care provid-ers in counseling women and men and assists health care providers to determine safe and eff ective contra-ceptive methods individualized to patient preferences and individual health issues It is available at www.cdc gov/ reproductivehealth/ unintendedpregnancy/ pdf/ legal_

summary- chart_ english_ fi nal_ tag508.pdf

14 Gynecologic

in their childbearing years Ninety- nine percent of women

aged 15 to 44 years have used at least one contraceptive

method Unfortunately, approximately 50% of all

preg-nancies in the United States are unintended Consistent

use of a reliable and eff ective contraceptive method can

greatly reduce the unintended pregnancy rate Easy access

and education regarding contraceptive use is a keystone in

the prevention of unintended pregnancy

Subjective Data

A Review complete menstrual history, including age of

onset, duration, frequency, regularity, and dysmenorrhea

Review date of last menstrual period (LMP)

B Review the patient’s pregnancy history

C Review the patient’s contraception and sexual history

D Note other medications the patient is taking including

over- the- counter (OTC) medications and supplements

E Ask the patient whether she has had a major medical

disease including hypertension, cardiovascular incident,

thromboembolic disease, diabetes, migraine headaches,

gallbladder disease, or liver disease

F Review substance abuse/ use history

G Review childhood illness and immunization record

H Note allergies

I Review pertinent family medical history

Physical Examination

A Check height, weight, blood pressure, pulse, and

body mass index (BMI)

B Inspect

1 Note overall appearance Look at neck roid) Inspect breast/ genitalia for Tanner staging See Appendix C: Tanner’s Sexual Maturity Stages

2 Skin assessment: Check for central hair growth,

which is responsive to androgens Areas to inspect for coarse hair include the upper lip, chin, sideburns, neck, chest, lower abdomen, and perineum

C Palpate

1 Palpate the neck for thyroid enlargement

2 Palpate the abdomen for enlarged organs or

uter-ine enlargement compatible with pregnancy

3 Perform breast examination, palpating for masses

Assess for nipple discharge

4 Palpate axilla for masses, and lymphadenopathy

D Auscultate

1 Auscultate the heart and lungs

2 If pregnancy is suspected, consider auscultating for

fetal heart tones

E Pelvic examination

1 Inspect external genitalia Note pubic hair pattern for

Tanner staging Note any lesions, masses, or discharge

2 Speculum examination: Inspect vagina and cervix

Note any vaginal discharge Obtain Pap smear and cervical/ vaginal cultures as appropriate

3 Bimanual examination: Palpate the cervix and check for cervical motion tenderness (CMT) Palpate the size of the uterus and assess for adnexal masses

4 Consider rectal examination as indicated

D Vaginal/ cervical cultures for sexually transmitted

infections (STIs) as indicated Plan

A General interventions

1 Review all methods of contraception available with

the patient and partner, if available

2 Consider all aspects of the client’s history and make recommendations as appropriate

B Patient teaching

1 Review anatomy and physiology of the menstrual

cycle and reproduction with all patients

2 Review the risks, benefi ts, costs, use, and effi cacy

of contraceptive methods Review perfect use versus typical use of method selected

3 Review STI prevention and limitations of STI

pre-vention as related to each method

4 Assist the patient in selecting the most

appro-priate method of contraception with regard to cost, effi cacy, health status of the patient, ability to use correctly and consistently, and the patient’s personal values

5 Warning signs and information as to when to call

the care provider should be given to all patients

6 All women of childbearing age should be

edu-cated on the availability and proper use of

Teaching Guide for this chapter, “Contraception:

How to Take Birth Control Pills (for a 28-Day Cycle).”

7 Provide all patients information on the prevention

of STIs

Methods of Contraception

A Abstinence: Refraining from sexual intercourse

1 Advantages: Easy and no cost Perfect use off ers

protection against STIs and pregnancy

2 Disadvantages: User dependent

B Barrier methods

1 Male condom

a Advantages:  Male condoms are easily

acces-sible (OTC with no prescription needed) and relatively inexpensive Condoms do not require daily intervention and off er some protections against STIs

b Disadvantages: Male condoms are technique

can occur Some condoms are made from latex, and those with latex allergies need to be aware and carefully check the label for latex content

Nonlatex condoms are available Male condoms are intended for one- time use only

▶

c Efficacy with perfect use of male doms:  Approximately 2 in 100 women will become pregnant each year With typical use of male condoms, approximately 15 in 100 women will become pregnant each year

2 Female condom

a Advantages:  Female condoms are easily

acces-sible (OTC with no prescription needed) and relatively inexpensive Condoms do not require daily intervention and off er some protections against STIs

b Disadvantages: Female condoms are technique

dependent for effi cacy Slippage and spillage can occur Th e female condom is intended for one- time use only and may be inserted up to 8 hours before intercourse

c Effi cacy with perfect use of the female dom: Approximately 5 in 100 women will become pregnant each year With typical use of the female condom, approximately 21 in 100 women will become pregnant each year

3 Diaphragm

a Advantages: Diaphragms are nonhormonal and

can be used for years with proper care May be inserted up to 6 hours before intercourse

b Disadvantages: Diaphragms must be properly

fi tted by an experienced health care provider and are user controlled Placement is crucial to contra-ceptive benefi t and spermicide must be used Must

be removed within 24 hours due to risk of toxic shock syndrome (TSS) Th e patient must have fi t checked after childbirth and weight gain or loss

Urinary tract infections (UTIs) may be more quent in diaphragm users, and some women may experience sensitivity or allergy to spermicide

fre-Avoid use during menses

c Effi cacy with perfect use of the diaphragm: 6 in

100 women will become pregnant each year With typical use of the diaphragm, 16 in 100 women will become pregnant each year

4 Cervical cap

a Advantages: Cervical caps are nonhormonal and

can be used for years with proper care Th e cervical cap may be inserted and left in place up to 48 hours

b Disadvantages: Cervical caps must be properly

fi tted by an experienced health care provider and are user controlled Placement is crucial to contra-ceptive benefi t and spermicide must be used Must

be removed within 48 hours due to risk of TSS

Th e FemCap is made of latex and not appropriate for latex- allergic patients Some women may expe-rience sensitivity or allergy to spermicide Avoid use during menses

c Effi cacy with use of the cervical cap is similar to the diaphragm

c Effi cacy with use perfects use of the vaginal sponge:  Among parous women, 20 in 100 will become pregnant each year, and 9 nulliparous women will become pregnant each year With typ-ical use, 32 in 100 parous women and 16 nullipa-rous women will become pregnant each year

C Surgery

1 Male sterilization

a Advantages: Sterilization is a very eff ective form

of contraception User does not have to ber to do anything before intercourse, and it is not user dependent Sterilization is permanent

b Disadvantages: Sterilization involves a surgical

procedure Insurance may not cover the cost of the procedure

c Effi cacy with perfect use of male sterilization;

0.1 in 100 women will become pregnant each year

With typical use of male sterilization 0.15 in 100 women will become pregnant each year

2 Female sterilization is the second most often used

contraceptive method in the United States

a Advantages: Sterilization is a very eff ective form

of contraception User does not have to ber to do anything before intercourse, and it is not user-dependent Sterilization is permanent

b Disadvantages:  Sterilization involves a

surgi-cal procedure If pregnancy does occur, there is a higher incidence of ectopic pregnancy Insurance may not cover the cost of the procedure

c Effi cacy with both perfect and typical use of female sterilization: 0.5 in 100 will become preg-nant each year

D Intrauterine device (IUD)

1 Hormonal (Mirena)

a Advantages:  Mirena is a very eff ective form

of contraception Mirena may be left in place for 5  years User does not have to remember

to use before intercourse Mirena may reduce menstrual fl ow

b Disadvantages: Risks of any IUD include

uter-ine perforation, increased spontaneous abortion, ectopic pregnancy, and pelvic pain and infection

Mirena must be inserted by a qualifi ed health care professional IUD may be spontaneously expelled

c Effi cacy with both perfect and typical use

of the Mirena:  0.2 in 100 will become pregnant each year

2 Nonhormonal (ParaGard)

a Advantages:  ParaGard is a very eff ective form

of contraception ParaGard may be left in place for

10 years User does not have to remember to use before intercourse

14 Gynecologic

b Disadvantages: Risks of any IUD include

uter-ine perforation; increased spontaneous abortion, ectopic pregnancy, and pelvic pain and infection

ParaGard must be inserted by a qualifi ed health care professional IUD may be spontaneously expelled

c Effi cacy with perfect use of the ParaGard: 0.6 in

100 women will become pregnant each year With typical use of the ParaGard, 0.8 in 100 women will become pregnant each year

Women who are not appropriate candidates for an IUD include those with recent pelvic infections, anatomical uterine abnormalities, and pregnancy

Caution should be exercised when considering an IUD in women who have multiple sexual part- ners; pelvic infl ammatory disease (PID); immu- nosuppression; undiagnosed, irregular, or heavy menstrual bleeding; abnormal Pap smear; and dif-

fi culty obtaining follow- up care See World Health Organization’s IUD Toolkit at www.k4health.org/

b Disadvantages:  Th e POP cannot be taken if the patient has any contraindications to progestin use POPs are less eff ective than COCs and must

be taken daily at the same time, requiring strict adherence to regime

c Effi cacy with perfect use of POPs: 0.3 in 100 women per year will become pregnant With typ-ical use, 8 in 100 women per year will become pregnant

2 Injection (Depo- Provera) long- acting depot medroxyprogesterone acetate (DMPA)

a Advantages:  Easy to use Th e user only has to remember the injection every 3  months May decrease vaginal bleeding DMPA is a safe hormonal alternative for women who cannot take estrogen

b Disadvantages:  Women cannot use DMPA if

they have any contraindications to progesterone use

May cause amenorrhea or irregular vaginal bleeding

May cause increased weight gain Requires routine (3 months) visits to the provider’s offi ce for intra-muscular (IM) injections DMPA does not provide protection against STIs DMPA is associated with reversible decreased bone mineral density

c Effi cacy with perfect use of DMPA: 0.3 in 100 women per year will become pregnant With typ-ical use, 3 in 100 women per year will become pregnant

d Depo- Provera should be administered during

the fi rst 5 days of the menstrual cycle, or tum before resumption of intercourse (preferably after lactation has been established) If this is not possible or if a woman is late for injection, admin-ister pregnancy test and have the patient use con-doms for at least 1 week after injection

3 Contraceptive implant (Nexplanon): Long- acting

reversible etonogestrel implant

a A single- rod subdermal radiopaque implant

b Advantages:  Progestin implant is a safe

hor-monal alternative for women who cannot take

contraceptive

c Disadvantages: Women cannot use Nexplanon

if they have any contraindications to progestin use Possible insertion and removal complications

d Th e manufacturer strongly recommends that care providers who wish to insert and/ or remove Nexplanon participate in training sessions Only clinicians who have completed the training pro-gram are eligible to purchase the product Th e link to request this training is www.nexplanon- usa.com/ en/ hcp/ services- and- support/ request- training/ index.asp

e Absolute contraindications to progestogen therapy

i Active thrombophlebitis or

thromboem-bolic disorders

ii Acute liver disease iii Known or suspected cancer of the breast

iv Pregnancy

v Undiagnosed, abnormal vaginal bleeding

4 Combined estrogen/ progesterone contraceptives:

Combined estrogen/ progesterone contraceptives come

in three delivery methods: Oral pills, a transdermal patch, and a vaginal ring Advantages and disadvan-tages and effi cacy are similar regarding hormones, but there are some diff erences in the delivery methods

a Advantages: Combined contraceptives are easy

to use, convenient, rapidly reversible, and trolled by women Th e transdermal patch is only changed weekly, and the vaginal ring is left in place for 3 weeks In addition to predictable menses, combined contraceptives decrease menstrual fl ow and length of menses

b Disadvantages: Dependent on user, and oral

pills must be taken daily Exposure to hormones may not be suitable for certain women based on health status and risk See absolute and relative contraindications that are not appropriate for some women in a prescriber’s reference guide Smoking

in conjunction with use of combined ceptive increases cardiovascular risk and should be considered Does not protect against STIs Other medications, such as anticonvulsants and antibiot-ics, may interfere with eff ectiveness of combined hormonal contraceptives and should be considered

contra-in prescribcontra-ing

c Effi cacy with perfect use of combined monal contraceptive: 0.3 in 100 women per year will become pregnant With typical use, 8 in 100 women per year will become pregnant

d Prescribing considerations:  Oral

contracep-tives come in combination extended cycle, bination monophasic, combination biphasic, combination triphasic, and progestin- only for-mulations Side eff ects can be managed in con-sideration of pill composition See prescribing reference guides such as the Monthly Prescribing Reference at www.empr.com General consid-erations for pill selection include age, health

Because POPs are highly sensitive to tency in timing, reserve prescriptions of them for women who have contraindications to estro-gen Alternatives for COCs should be consid-ered in women older than 35 years who smoke due to increased risks of thrombolytic events

consis-In asymptomatic adolescents, it is acceptable

to prescribe COCs without an initial pelvic examination For adolescents or anyone who may have diffi culty remembering to take a daily pill, consideration should be given to prescrip-tion of the vaginal ring, patch, or other meth-ods See the offi ce’s prescriber’s reference for complete information on safety side eff ects and contraindications

e Absolute contraindications to estrogen therapy

(ET)

i Acute liver disease

ii Cerebral vascular or coronary artery

dis-ease, myocardial infarction (MI), or stroke

iii History of or active thrombophlebitis or

thromboembolic disorders

iv History of uterine or ovarian cancer

v Known or suspected cancer of the breast

vi Known or suspected estrogen- dependent

neoplasm

vii Pregnancy viii Undiagnosed, abnormal vaginal bleeding

f Relative contraindications to ET

i Active gallbladder disease

ii Familial hyperlipidemia

5 Spermicide (foam, fi lm, gel, tablets, and suppositories)

a Advantages: Spermicide is a nonhormonal OTC

preparation and contains nonoxynol- 9 It is pensive and easily accessible

b Disadvantages: Spermicide is user controlled and, if not used consistently, will lead to contra-ception failure Some may experience sensitivity or allergy to spermicide Spermicide has a high failure rate

c Effi cacy with perfect use of spermicide:  18 in

100 women will become pregnant each year With

typical use of spermicide, 29 of 100 women will become pregnant each year

F Natural family planning (NFP)

1 Advantages: NFP is nonhormonal It has no cost

and is easy to use

2 Disadvantages: NFP is user controlled and depends

on regularity of cycle and avoidance of intercourse

Can be complex for user and has a high failure rate

Does not protect against STIs

3 Effi cacy with use:  With typical use of the ity awareness method, 25 in 100 women will become pregnant each year

fertil-Additional information, training, and patient teaching may be found at the following websites:

Association of Reproductive Health Professionals ( www.arhp.org/ Publications- and- Resources/

Quick- Reference- Guide- for- Clinicians/ choosing/

Fertility- awareness ), Institute for Reproductive Health ( www.irh.org ), and Planned Parenthood ( www plannedparenthood.org )

G Withdrawal

1 Advantages: Withdrawal is nonhormonal, is

inex-pensive and easily accessible

2 Disadvantages:  Withdrawal is user controlled

Withdrawal has a high failure rate and does not tect against STIs

3 Effi cacy with use: With typical use of withdrawal method, 85 in 100 women will become pregnant each year

Follow- Up

A Th e patient should return in 3 months of initiation of oral contraceptives, ring, and patch to assess blood pres-sure, use, side eff ects, and satisfaction Th en yearly visits are recommended for health maintenance

B Patients on Depo- Provera injections should return

every 3 months for follow- up injection and weight ation and then yearly for health maintenance

C Patients with a diaphragm should return for refi

t-ting with change in weight or postpartum and for routine health maintenance

Consultation/ Referral

A If the contraceptive method selected is one the

prac-titioner is not experienced in providing (diaphragm, implant, IUD, surgical sterilization), refer to an experi-enced appropriate provider

Individual Considerations

A Adults

1 Discontinue COCs for women aged 35 years and

older who smoke

2 Increased age and obesity increase risk of venous

thromobembolism with the use of COCs COCs should be prescribed with caution and alternative contraceptives should be considered

14 Gynecologic

3 Th e health care provider should continue to assess for chronic conditions and medication use and weigh risks and benefi ts of selected methods

4 Provide anticipatory guidance regarding the need

to use contraceptives until menopause is confi rmed to prevent unintended pregnancy

B Adolescents

1 A pelvic examination is not required and should not

become a barrier to access to contraception Long- acting reversible contraceptives and methods that require less frequent dosing (patch, ring) promote adherence and continuation and should be encouraged in teens

2 Education and counseling regarding pregnancy and STI prevention are essential

3 Many clients have mobile phones with reminder

apps that assist in compliance with contraceptive use

Dysmenorrhea

Rhonda Arthur

Defi nition

Dysmenorrhea is painful uterine cramping felt

primar-ily in the lower abdomen but also in the lower back and

upper thighs

A Primary dysmenorrhea:  Not associated with pelvic

pathology; usually associated with ovulatory cycles Occurs

on the fi rst or second day of the menstrual period; usually

worse the fi rst day; aff ects teens and women in their 20s; is

often associated with prostaglandin- induced symptoms of

diarrhea, nausea, vomiting, and/ or headache

B Secondary dysmenorrhea: Painful uterine

contrac-tions due to a pathologic etiology such as endometriosis

or pelvic infl ammatory disease (PID) Primarily occurs in

women in their 20s, 30s, and 40s

Incidence

A Primary dysmenorrhea is very common, aff ecting up

to 90% of young women to some extent at some time

Dysmenorrhea frequently leads to absenteeism from work

or school and impacts limitations on social and sports

activities Th e incidence of endometriosis is 8% to 30%

of women of reproductive age

Pathogenesis

A Primary dysmenorrhea is due to myometrial

contrac-tions that are caused by prostaglandins in the secretory

endometrium Th e prostaglandins cause uterine ischemia

through platelet aggregation, vasoconstriction, and

dys-rhythmic contractions

B Secondary dysmenorrhea is associated with

patho-logic conditions such as endometriosis, cervical stenosis,

tumors, adhesions, adenomyosis, myomas, polyps,

infec-tion (pelvic infl ammatory disease [PID]), intrauterine

device (IUD)- retained products of conception, or

non-gynecologic causes Th e pain of secondary dysmenorrhea

may also be unrelated to menses

C In endometriosis, there are islands of endometrium

found on peritoneal surfaces of the bladder, broad

liga-ments, fallopian tubes, ovaries, bowel, and cul- de- sac, as

well as distant sites on the abdominal wall, vagina, lung,

or other sites

Predisposing Factors

A Female

B Reproductive age

C Normal menstrual function

D Cervical stenosis, possibly

Common Complaints

A “I have painful periods.”

B “My menstrual cramps are terrible, particularly the

fi rst day of my cycle.”

C “My cramps are so bad I feel sick to my stomach and

have diarrhea.”

Other Signs and Symptoms

A History of menstrual cramps just before the onset

of the menstrual period and for the first 24 to 48 hours

B Pain beginning earlier; associated with intercourse,

defecation, and urination; and lasting throughout the menstrual period is associated with endometriosis or adenomyosis

C Acute pain may be associated with infection (PID) or

ectopic pregnancy

Subjective Data

A Obtain a complete menstrual history: Age at

men-arche; frequency, duration, and regularity of periods;

amount of fl ow in number of perineal pads or tampons used

B Ask the patient about the location of the pain; note

radiation and associated symptoms such as nausea, ing, or diarrhea

C Is pain rhythmic or spasmodic (primary) or steady

(secondary)?

Primary dysmenorrhea usually begins 2 to 3  years after menarche

E Inquire about the type of contraception used

F Obtain obstetric history

G Is the pain related to the menstrual period, or does it

occur before or independent of the menstrual period?

H Does the patient have dyspareunia?

1 Examine the general body habitus for female

adi-pose distribution on the buttocks and thighs

2 Note breast development (see Tanner’s Sexual Maturity Stages in Appendix C)

3 Observe the abdomen for distension

C Palpate and percuss

1 Examine the abdomen for masses or tenderness

1 Inspect the external genitalia for pubic hair

pat-tern, lesions, discharge, and odor

2 Palpate the external genitalia for masses or areas of

tenderness

F Speculum examination: Inspect the cervix and vagina

for discharge, lesions, ectropion, cervical erosion, and IUD string

5 A normal pelvic examination is a signifi cant

fi nding in primary dysmenorrhea and often in endometriosis

Diagnostic Tests Primary dysmenorrhea is often diagnosed by history, including symptoms and timing in menstrual cycle and pelvic examination If secondary dysmenorrhea is sus-pected and additional information is required, the care provider may consider the following diagnostic tests:

A Consider pelvic ultrasonography to rule out pelvic

pathology

B Laboratory studies: Urinalysis, hemoglobin (Hgb), hematocrit (Hct), and white blood cell (WBC)

C Consider vaginal and cervical cultures for chlamydia

and gonorrhea, if infection is suspected

D Pregnancy test as indicated

E Papanicolaou (Pap) smear per guidelines

Differential Diagnoses

A Dysmenorrhea: Th e patient’s history and a mal pelvic examination are used to diagnose primary dysmenorrhea

B Complication of pregnancy:  Missed or incomplete

abortion or ectopic pregnancy

A General interventions

1 Support patient concerns and identify reality of

discomfort Identify primary source of pain if other diagnoses exist

B Patient teaching:

1 See Section III: Patient Teaching Guides for this

chapter, “Dysmenorrhea (Painful Menstrual Cramps

or Periods)” and “Contraception: How to Take Birth Control Pills ( for a 28-Day Cycle).”

2 Educate the patient about the physiology of menstruation

3 Teach the patient that endometriosis is one of the

leading causes of infertility

4 Encourage activity and exercise, such as walking or

swimming

5 Advise warm baths or heating pads to help relieve

some pain

C Pharmaceutical therapy

1 Nonsteroidal anti- infl ammatory drugs (NSAIDs)

are the drugs of choice

a Th ey inhibit prostaglandin synthesis in the endometrium, thus decreasing uterine cramping

Th ere is also an analgesic eff ect

b Th e fenamates have been the most eff ective, followed by the propionic acid derivatives

c Th e drugs should be started as the menstrual period begins It is no longer considered the stan-dard of care to begin the drugs a few days before the onset of the menstrual period

d Prostaglandin inhibitors relieve dysmenorrhea

in 80% of women

e Take NSAIDs with food to avoid

gastrointesti-nal (GI) upset and irritation

2 Medications of choice for dysmenorrhea

ii Propionic acid derivatives:  Ibuprofen

(Advil, Motrin, Nuprin) 200 to 800 mg every 4

to 6 hours; ketoprofen (Orudis) 12.5 to 25 mg every 4 to 6 hours Th ese are over- the- counter (OTC) medications

iii Anthranilic acid derivatives:  Mefenamic

acid (Ponstel) 500 mg initial dose, then 250 mg

to 3 days

iv Benzeneacetic acid derivatives: Diclofenac

potassium (Catafl am) 50 mg three times per day Initial dose of 100 mg may be given

b Hormonal control

i Oral contraceptive pills: Any combination pill is effi cacious Consider extended cycle dos-ing to prevent having monthly periods

ii Nuvaring iii Depo- Provera

14 Gynecologic

c With physician consultation or referral,

dan-azol (Danocrine)

gonadotropin- releasing hormone (Gn- RH) agonists such as nafarelin (Synarel), leuprolide acetate (Lupron, Lupron Depot), and goserelin acetate (Zoladex) Follow- Up

A Have the patient return in 3 months Encourage the

patient to undergo the treatment for 3 months to

deter-mine the eff ectiveness

Consultation/ Referral

A If dysmenorrhea does not respond to NSAIDs or

oral contraceptives, consult with a physician for further

workup to determine the source of the pain

B Consider consultation with obstetrics and gynecology

(OB/ GYN) for laparoscopy or hysteroscopy to diagnose

endometriosis or adhesions Laser may be used to destroy

endometrial implants or to lyse adhesions

Individual Considerations

A Pregnancy: Uterine contractions in pregnancy could

be preterm labor

B Adolescents

1 Remember that endometriosis can occur in this

age group It is not an extremely rare fi nding

C Adults

1 Endometriosis can be a disabling condition

inter-fering with work and sexual relationships It may tinue into the perimenopausal period

Dyspareunia

Rhonda Arthur

Defi nition

A Dyspareunia is genital or pelvic discomfort associated

with sexual intercourse (entry or deep penetration) and

interferes with sexual satisfaction Dyspareunia may be

superfi cial, relating to vulvar and vaginal pain, or it may

be deep, relating to deep, pelvic pain Vaginismus is the

involuntary (often painful) contraction of the pelvic fl oor

muscles in response to pressure or attempted penetration

Incidence

A Vaginismus occurs in 1% to 6% of women and

dyspa-runia occurs in 8% to 22% of postmenopausal women

i Pelvic infl ammatory disease (PID)

ii Uterine or ovarian tumors iii Adenomyosis

iv Pelvic scarring or adhesions versus endometriosis

3 Musculoskeletal anomalies

a Disk disease

b Myofascial pain

c Coccygodynia

4 Extensive prolapse or organ displacement

5 Urethral syndrome or other urinary tract disorders

6 Vulvodynia

7 Gastrointestinal (GI) anomalies

a Constipation

b Irritable bowel syndrome (IBS)

c Infl ammatory bowel disease (IBD)

2 Fear of pain, infection, or pregnancy

3 Pelvic congestion syndrome

4 Poor partner communication

5 History of sexual assault, including date rape

6 Previous trauma during intercourse

7 Domestic violence

Common Complaints

A Irritation or burning with intercourse

B Lack of vaginal lubrication

C Pain with vulvar or vaginal contact

D Pain with deep penetration

A Review the onset, duration, and course of presenting

symptoms including precise location and timing of pain during intercourse

B Review the patient’s medical or surgical history for

physical causes (see “Pathogenesis” section)

C Ask:  How often does pain occur (with every

inter-course, near periods, or in certain sexual positions)?

What relief measures have been tried? Is there ment with using extra lubrication? How much relief was obtained with each measure?

D Obtain a complete sexual history including the following:

1 Sexual practices

2 Sexual satisfaction or orgasm

3 Perception of partner satisfaction

4 Age at fi rst coitus

5 History of sexual abuse, molestation, rape

6 Perceptions regarding sexuality

7 Number of sexual partners and preferences

8 Time spent on foreplay

9 History of recent delivery and breastfeeding

10 Age at onset of puberty, date of last menses, and

cycle history

11 Current method of birth control and satisfaction

with method; previous methods and why they were discontinued

12 Presence of vaginal discharge, odor, dysuria, or

other physical symptoms before or after intercourse

13 Medications, including prescription and over-

the- counter (OTC) drugs

14 Can the woman insert a tampon without pain?

Physical Examination

A Check temperature, pulse, respirations, and blood pressure

B Inspect: Observe generally for discomfort before,

dur-ing, and after examination

Look for signs of physical or sexual abuse, cuts, bruises, and lacerations For pain greatest on deep penile pen- etration, suspect PID, ovarian cyst, endometriosis, pel- vic adhesions, relaxation of pelvic support, or uterine

fi broids

C Auscultate

1 Th e abdomen for bowel sounds in all quadrants;

Auscultation of the abdomen should precede any pation or percussion due to the changes in intensity and frequency of sounds after manipulation

D Palpate

1 Palpate the abdomen for masses; check for

supra-pubic tenderness

2 Examine the back, assess range of motion Observe

for evidence of disk disease, myofascial pain, and cygodynia Palpate for costovertebral angle (CVA) tenderness

E Pelvic examination

1 Inspect:  Perform perineal examination for

atro-phic vaginitis Atroatro-phic vaginitis presents as red, shiny, smooth vagina (loss of rugae); vaginal thinning;

decreased elasticity of vaginal tissues Vulvar infl mation may be present Assess discharge and rugae for hormonal support

2 Evaluate the patient for vulvovaginitis Perform

vul-var examination for Bartholin’s gland enlargement, fi sures, condyloma, and herpes Inspect for anatomic variants: narrowed introitus, congenital malforma-tions (septum), and pelvic relaxation (cystocele and rectocele)

F Speculum examination:  Inspect for cervicitis, bility, and discharge If the woman can insert a tampon without pain, a mechanical obstruction is unlikely

G Bimanual examination: Check cervical motion

ten-derness (CMT); adnexal masses; and uterine size, tency, and position

H Rectovaginal examination:  Palpate uterosacral

liga-ments for pain and nodularity and other signs of PID and endometriosis In cases of rectal trauma, cultures may be needed to rule out STIs if anal intercourse is practiced

Diagnostic Tests

A Wet prep to rule out candidiasis, trichomoniasis, and rial vaginosis (BV)

B Cervical cultures for chlamydia, gonorrhea

C Viral cultures of lesions, if any

D Urine culture, if applicable

E Pelvic ultrasonography, if indicated

F Stool culture, if applicable

G Sedimentation rate, if indicated by physical

3 A secure, trusting relationship must be established

with the care provider before many patients feel fortable discussing sexuality issues Continuity with one provider is essential

4 Patients with dyspareunia should be evaluated for multiple etiologies Treat underlying pathologies such as musculoskeletal anomalies, pelvic infection, urinary tract infection (UTI), STDs, hormonal defi -ciencies, and GI etiologies (see specifi c chapters for treatment plans and drug therapy)

B Patient teaching

1 See Section III: Patient Teaching Guide for this

chap-ter, “Dyspareunia (Pain With Intercourse).”

C Pharmaceutical therapy

1 Refer to specifi c chapter for therapies related to

etiology

2 Vulvodynia:  Consider the use of topical agents

applied to the vulva or vestibule, antihistamine apy, and/ or tricyclic antidepressants

a Lidocaine (Xylocaine) 2% gel applied to vulva,

vestibule, and fourchette

A Perform test of cure for all diagnosed infections, if

indicated (see specifi c infection and therapy)

B Refer to follow- up plans for specifi c etiology

▶

14 Gynecologic

Consultation/ Referral

A Refer the patient to a gynecologist for removal of

cysts, endometriomas Laparoscopy is indicated if

endo-metriosis, adhesions, or an adnexal mass is suspected

B Refer the patient to a gynecologist for

vulvovagi-nal anomalies, including thickened hymen, shortened

vagina, vaginal agenesis; vaginal dilator therapy may

be tried

C Refer the patient for sexual therapy

consulta-tion for continued complaints without an identifi able

physical cause

Individual Considerations

A Pregnancy or postpartum

1 Sexual intercourse may continue throughout

preg-nancy unless there is pain, bleeding, preterm labor,

or premature rupture of the membranes Alternate positions should be suggested by the provider Sexual intercourse may resume in the postpartum period when the bleeding has decreased or stopped, incision

or episiotomy is healed, and the woman is comfortable upon fi nger insertion and test of vaginal discomfort

2 Breastfeeding causes hormonal changes that may

produce a menopause- like state, and extra lubrication

is usually required

B Partners

1 Encourage the patient to have partner(s)

partici-pate in sexual health counseling

Emergency Contraception

Rhonda Arthur

Defi nition

A Emergency contraception is a prospective method of

pregnancy prevention when unprotected intercourse or

birth control failure occurs

Incidence

A One in nine sexually active women report using

emer-gency contraception, with the highest use rate among

women aged 20 to 24 years Th e intent is to increase the

use of emergency contraception to reduce the number of

unintended pregnancies and thus reduce the number of

abortions and deliveries of truly unwanted children More

than 43 million women are not using birth control and

are at risk of unintended pregnancy

Pathogenesis

A Hormones in oral contraceptive pills

temporar-ily disrupt ovarian hormone production and cause an

absent or dysfunctional luteal phase hormone pattern

Th is results in an out- of- phase endometrium that is

unsuitable for implantation Hormone disruption may

likewise interfere with fertilization and cause

disor-dered tubal transport Hormones or minerals (copper)

in an intrauterine device (IUD) cause an infl ammatory

response to occur, which make the endometrium

unsuit-able for implantation and interfere with fertilization and

transport

Predisposing Factors

A Rape

B Failure of other means of birth control, including

broken condom, dislodged diaphragm or cervical cap, expelled IUD, lost or forgotten pills

C Unprotected intercourse

Common Complaints

A “I’m worried that I  might get pregnant because the

condom broke.”

B “My diaphragm slipped.”

C “I went on vacation and forgot my pills.”

Other Signs and Symptoms

A Unprotected intercourse

Subjective Data

A Elicit a menstrual history When was the patient’s last

menstrual period (LMP)? Are her periods regular?

B What form of contraception was used, if any?

C Has the patient experienced any early signs of

preg-nancy? If so, discuss

D Ask about early symptoms of pregnancy such as

fre-quency of urination, nausea, breast tenderness, and late or missed period

E Ask the patient about her feelings or plans if she

should get pregnant

Physical Examination

A Check blood pressure, pulse, and weight

B Inspect abdomen for enlargement compatible with

pregnancy

C Palpate abdomen for uterine size; if fundus is

palpa-ble, measure for fundal height

D Auscultate

1 Heart and lungs

2 Abdomen If the uterus is enlarged and is

mea-sured to be greater than 11 weeks gestation, attempt

to hear fetal heart tones with fetal Doppler

E Pelvic examination

1 Inspect the external genitalia for lesions; note female pubic hair pattern

2 Speculum examination:  Observe for bluish color

of cervix (Chadwick’s sign) Observe vaginal charge; note color and odor

3 Bimanual examination:  Palpate the cervix for softening associated with early pregnancy Palpate uterine size

C Dysfunctional uterine bleeding (DUB)

D Amenorrhea from anovulation

E Polycystic ovary syndrome (PCOS)

F Perimenopause

2 Discuss the likely risk of pregnancy

3 Explore the patient’s feeling about continuing pregnancy

4 Decide whether a physical examination and

nancy test are needed if there is a possibility of a nancy from the previous month

B Patient teaching

1 See Section III: Patient Teaching Guides for this

chapter “Emergency Contraception—Levonogesterel” or

“Emergency Contraception—Ulipristal Acetate” based

on selected method

2 Discuss options, risks, failure rates, necessary follow- up, alteration of menstrual period, and warn-ing signs of complications

3 Discuss interim plan for contraception

4 Advise the patient to take oral contraceptive pills as

prescribed or have an IUD inserted within 96 hours

of unprotected intercourse

5 Treatment is most eff ective if taken within

72 hours for progestin–estrogen methods and within

120 hours for a progestin antagonist

6 Treatment is not eff ective in an already established

pregnancy

7 Educate the patient about the possibility of

men-strual cycle disturbance with the next menmen-strual period

8 If menstrual bleeding does not begin within

3 weeks, evaluate for possible pregnancy

9 Emergency contraception is not associated with

an increased incidence of abnormal outcome of nancy, should pregnancy not be averted Emergency contraception does not always work

10 Th is is not to be used as a primary contraceptive method

11 Have prescription or pack of pills available for an

emergency situation

12 Th e IUD should be used only for women at low risk for pelvic infl ammatory disease (PID) and when the woman intends to continue use of the IUD for contraception

C Pharmaceutical therapy

Choosing the best method for emergency ception (EC) should be based on day and time of unprotected intercourse; body mass index (BMI);

contra-breastfeeding; and recent (within 5  days) use of pill, patch, or ring

1 IUD— Most eff ective and can be used up to

120 hours after unprotected intercourse

Pharmaceuticals) must be inserted within 5 to

7 days after ovulation in a cycle when unprotected intercourse has occurred Th e advantage is that the IUD may be left in place for continuing contra-ception for 10 years

b Mechanism of action:  Two ideas have been proposed

i IUD leads to endometrial changes that

prohibit implantation

ii Th e copper ions have a direct toxic eff ect

on the embryo

2 Emergency contraception oral formulations

a Ella (ulipristal acetate) is a progesterone agonist/

antagonist that is available only by prescription

Cannot be used in breastfeeding women May be less eff ective in women with a BMI greater than 35

May not be as eff ective as Levonorgestrel emergency contraceptive if the woman has used birth control pills, patch, or ring within the past 5 days

i One tablet is taken orally as soon as

pos-sible after unprotected intercourse within

120 hours (5 days)

ii Common side eff ects are headaches,

abdom-inal pain, and nausea Less common side eff ects include dysmenorrhea, fatigue, and dizziness

iii Repeated use of ella within the same

men-strual cycle is not recommended

iv If vomiting occurs within 1 to 3 hours of

taking a dose, take another dose

v Educate the patient about common side

eff ects such as breast tenderness, abdominal pain, headache, and dizziness

vi Because Ella and the progestin

compo-nent of hormonal contraception bind to tor sites, women wishing to use hormonal contraception after use of Ella should not do so until 5 days after Ella use, but should be coun-seled on alternative non hormonal pregnancy prevention methods

b Levonorgestrel emergency contraceptive, commonly called “morning after pill” is available under the brand names “Plan B One- Step,” “My Way,” and “Next Choice,” and is available in one

progestin- only ECs are available unrestricted as over- the- counter medicines Less eff ective for women with a BMI greater than 25 and may not be eff ective for women with a BMI greater than 30

i Levonorgestrel 1.5 mg tablet should be

taken as soon as possible after unprotected sex (no later than 72 hours)

c Using a standard packet of oral

contracep-tives: Two doses of a combination of ethinyl estradiol and norgestrel or levonorgestrel,

12 hours apart Table 14.1 provides the alent dosing that may be used as an emergency contraceptive

i Method must be used within 72 hours

of unprotected intercourse Treatment is most eff ective if taken within 12 to 24 hours

ii Side eff ects of nausea and vomiting

with emergency contraception are common

Take each dose with food Take antiemetic,

▶

14 Gynecologic

dimenhydrinate (Dramamine) 50 mg orally,

30 minutes before dose of medication

iii If vomiting occurs within 1 to 3 hours of

taking a dose, take another dose

iv Educate the patient about common side

eff ects such as breast tenderness, abdominal pain, headache, and dizziness

Follow- Up

A Have the patient return in 3 to 4 weeks if she does not

have a menstrual period If she has a menstrual period,

recommend that she return in 1 month to assess

contra-ceptive use and off er options

in chronic pelvic pain and infertility Endometrial lesions have been found in the vagina, gastrointestinal (GI) tract (especially the sigmoid colon), thoracic cavity, limbs, and gallbladder

Incidence

A Th e true incidence of endometriosis is unknown

Ranges of 5% to 30% have been cited Positive ily history (mother or sister) increases the risk tenfold

fam-Endometriosis does not have a higher incidence for any particular race or socioeconomic group

Pathogenesis

A Retrograde menstruation is the most popular theory

for the etiology of endometriosis Menses are suspected

of “fl owing backward” through the fallopian tubes, resulting in the “seeding” of endometrial tissue outside the uterus

Predisposing Factors

A Positive family history, mother and/ or sister

B History of progressive dysmenorrhea

C History of prolonged uninterrupted menstrual cycles;

fi rst pregnancy at a late age

D Limited or no prior use of hormonal contraceptives

Common Complaints

A Pain before period

B Pain with intercourse

TABLE 14.1 Emergency Contraception

Antiprogestin Emergency Contraception Pill

Directions for antiprogestin pills: Take one pill within

120 hours

Brand

Number of

Pills per Dose

Progestin- Only Emergency Contraceptive Pill

Directions for progestin- only pills: Take one dose within

72 hours of intercourse

Brand

Number of

Pills per Dose

Ethinyl

Estradiol (mcg)/

Next

Choice One Dose

Combine Oral Contraceptive (COC) Pills for Emergency

Contraception

Directions for COC pills: Take fi rst dose within 72 hours and

repeat dose in 12 hours

Brand

Number of

Pills per Dose

Ethinyl

Estradiol (mcg)/

Dose

Levonorgestrel

(mg)/ Dose

Ovral 2 white pills 100 0.50

Lo/ Ovral 4 white pills 120 0.60

Triphasil 4 yellow pills 120 0.50

Tri- Levlen 4 yellow pills 120 0.50

Alesse 5 pink pills 100 0.50

C Pain with bowel movements; may include

constipa-tion from the fear or pain of having a bowel movement (dyschezia)

D Vaginal spotting and bleeding

Other Signs and Symptoms

A Dyspareunia and/ or pain that radiates to the thigh

B Chronic, noncyclic pelvic pain

C Abnormal vaginal bleeding:  Premenstrual spotting

and dysfunctional uterine bleeding (DUB)

D Other bowel symptoms: Diarrhea and rectal bleeding

E Urinary symptoms: Dysuria, urgency, and hematuria

Subjective Data

A Review the onset, duration, and course of complaints

B Question the patient regarding menstrual history:

Interval and duration of menstrual cycles and history of dysmenorrhea

C Question the patient regarding former use of

hor-monal contraceptives, including levonorgestrel (Norplant System), birth control pills, medroxyprogesterone (Depo- Provera), and progesterone (Progestasert intrauterine device [IUD])

D Question the patient regarding change in bowel

pat-terns or habits or pain with defecation

1 Note general appearance for discomfort before,

during, and after examination

2 Perform detailed external genitalia examination

C Auscultate

1 Abdomen for bowel sounds in all quadrants

Auscultation of the abdomen should precede any pation or percussion due to the changes in intensity and frequency of sounds after manipulation

D Palpate

1 Palpate abdomen for masses

2 Check for suprapubic tenderness

3 Back:  Check for costovertebral angle (CVA) tenderness

E Pelvic examination

1 Speculum examination:  Inspect the cervix for cervicitis; friability; and discharge color, odor, and amount Note any cutaneous lesions of the vagina, cervix, and perineum that resemble “powder burn or chocolate spots.” Laparoscopic fi ndings frequently reveal “powder burn” lesions of endometrial implants along the uterosacral ligament, pelvic peritoneum, ovaries, sigmoid colon, and other pelvic organs

2 Bimanual examination: Check for cervical motion

tenderness (CMT), adnexal masses; check uterine size, consistency, position, and mobility

Th e most common indicator of endometriosis is

a fi xed retroverted uterus with nodularity felt along the uterosacral ligaments Palpation of endo- metrial implants may result in exquisite pain for the patient

3 Rectovaginal examination: Palpate uterosacral

liga-ments for pain and nodularity Evaluate for masses and polyps of rectum A rectal examination is done because the uterus is often fi xed in a retroverted position due

to endometriosis Th e endometrial nodules present on the posterior uterine wall, cul- de- sac, and uterosacral ligament may be distinguished better rectally

Diagnostic Tests

Th ere are no specifi c diagnostic tests for endometriosis

Defi nite diagnosis is done by laparoscopy

A Serum beta human chorionic gonadotropin (HCG)

to rule out ectopic pregnancy

B White blood cell (WBC) to rule out infection

C Cervical culture for chlamydia or gonorrhea, to rule out sexually transmitted infection (STI) and pelvic infl ammatory disease (PID)

D Urine culture, if indicated

E Transvaginal ultrasonography, to rule out cysts and masses

F GI series or barium enema, if indicated

I Pregnancy: Normal, missed abortion, or ectopic

J GI or genitourinary (GU) complaints:  Diverticular

disease, spastic colon, or urinary tract infection (UTI) Plan

A General interventions

1 After surgical confi rmation, the practitioner may

comanage endometriosis with a physician

B Patient teaching

1 Treatment goals include prevention of disease

pro-gression, alleviation of pain, and establishment or toration of fertility Treatment options include the following:

a Observation alone

b Medical therapy or pharmacological therapy

c Referral or consultation for laparoscopic

ther-apy, including laser vaporization and removal of adhesions

2 Continuation or recurrence of pelvic pain may

necessitate assisting the woman to manage her chronic pelvic pain and dysmenorrhea with nonsteroidal anti- infl ammatory drugs (NSAIDs) therapy and/ or other

14 Gynecologic

non- narcotic chronic pain therapies, such as tion and biofeedback

3 Hysterectomy and bilateral salpingo- oophorectomy

are the only defi nitive cures for women who do not wish to conserve their reproductive capacity Th is should be considered only as a last resort for failed conservative treatment

C Pharmaceutical therapy: Diagnosis must fi rst be

con-fi rmed by laparoscopy

1 Mild endometriosis

a Combined oral contraceptive (COC) pills are

considered the fi rst- line therapy If the patient experiences pain during the week of withdrawal bleeding, she may take active pills continuously, omitting the placebo pills of the “off  week.”

Combination oral contraceptives are being used to duce a state of pseudopregnancy that should induce regression of the disease

b Medroxyprogesterone acetate 20 to 100 mg daily, norethindrone acetate 5 to 15 mg daily, or megestrol acetate 40 mg daily, or a long- acting progestin (Depo- Provera) 150 mg by intramuscu-lar (IM) injection every 3 months

2 Moderate to severe complaints

a Gonadotropin- releasing hormone (Gn- RH)

agonist

i Leuprolide acetate (Lupron) 3.75 mg by

IM injection every month

ii Nafarelin (Synarel) nasal spray twice daily

Use of a Gn- RH agonist, which acts to suppress lation, can result in side eff ects, including hot fl ashes, mood changes, and other menopausal symptoms Use is restricted to 6 months to avoid decrease in bone density

ovu-Expense of this therapy may preclude its use

b Danazol 400 to 800 mg daily for up to 6 months

i Use of danazol, which acts to produce anovulation and hypogonadotropism, can result in androgenic side eff ects, including acne, hirsutism, weight gain, and voice changes that may not be reversible

ii Other side eff ects, which are reversible,

include decreased breast size, atrophic vaginitis, dyspareunia, hot fl ashes, and emotional liability

Follow- Up

A Patients must return monthly while receiving Gn- RH

agonist or danazol therapies to assess for symptom relief

and side- eff ect profi le

Consultation/ Referral

A Th e workup, evaluation, and medications for

endo-metriosis are expensive Refer to a gynecologist for

ini-tial management A  prudent approach is recommended

with a conservative treatment option; evaluate the results

before trying another

B Refer the patient for a surgical consultation for defi nitive diagnosis Endometriosis may be suspected based on symptoms and physical examination It can-not, however, be confi rmed unless actually visualized by laparoscopy

Individual Considerations

A Pregnancy

Treatment may, therefore, be focused on sis abatement and fertility support

Resource Endometriosis Association

8585 North 76th Place Milwaukee, WI 53223 (414) 355 2200 www.endometriosisassn.org Female Sexual Dysfunction

Nancy Pesta Walsh

Defi nition

A Any persistent problem with desire, sexual response,

or function, which may aff ect the patient and her tionship, and occurs for at least 6 months It is classifi ed into subtypes:

1 Desire disorder:  Lack of interest or desire (most

common)

2 Arousal disorder: Inability to become aroused during sexual activity; absent or reduced genital sensations

3 Orgasm disorder:  Delay, absence, or decreased intensity of orgasm

a Primary: Th e patient has never had an orgasm

b Secondary: Th e patient has achieved orgasm in the past, but is unable to achieve orgasm at the time of presentation

4 Pain disorder:  Genitopelvic pain/ penetration

disorder (formerly dyspareunia and vaginismus)

Th is is described as pelvic or vulvovaginal pain ing vaginal penetration, anxiety, and/ or fear related

dur-to the thought of vaginal penetration, or marked tightening of pelvic fl oor muscles during vaginal penetration

Incidence

A Aff ects an estimated 22% to 43% of women

world-wide, and 14% of women aged 45 to 64 years Only 12%

have diagnosable disorders Th is includes women who report issues with sexual desire (64%), arousal diffi culty (31%), and pain (26%)

Pathogenesis

A Multiple models exist to describe the phases of

nor-mal sexual function

1 Masters and Johnson— consists of the stages of

excitement, plateau, orgasm, and resolution

2 Kaplan and Leif— consists of desire, excitement,

and orgasm

Female Sexual Dysfunction

3 Basson— consists of emotional intimacy,

sex-ual stimuli, psychological factors, and relationship satisfaction

B Sexual dysfunction includes various biological,

psy-chological, and social components

1 Biological factors include aging; medical

condi-tions such as diabetes and hypertension, and ing testosterone or estrogen

2 Psychological factors include depression or anxiety,

history of sexual abuse, childhood trauma, personality disorders, body image disorders, and perceived stress

3 Social factors include cultural or religious values,

relationship issues, career issues, fi nancial hardship, and household responsibilities

C Diagnosis is made based on the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5; 2013) and requires the following: Symptoms

experiences personal distress; symptoms are not a result

of substance or medication use, or medical conditions;

and symptoms are not related to a nonsexual medical disorder

D Orgasm disorders can be caused by neurologic and/

or vascular disease such as spinal cord injury, diabetes, or multiple sclerosis

5 Calcium channel blockers

6 Angiotensin- converting enzyme (ACE) inhibitors

1 Menopausal women aff ected more frequently Low

sexual desire may result from decreasing hormone els, specifi cally testosterone and estrogen levels Low estrogen levels are also linked to vulvovaginal atrophy

lev-and dyspareunia, both of which may decrease sexual desire in women

Common Complaints

A Women

1 Absence of orgasm

2 Pain during vaginal penetration

3 Diffi culty relaxing pelvic fl oor muscles to allow vaginal penetration

B Both sexes

1 Lack of interest or desire (most common)

2 Inability to become aroused

3 Pain with intercourse

C Men: Common complaints for men are specifi cally

discussed in Chapter 11: Gastrointestinal guidelines

Other Signs and Symptoms

A Vaginal discharge

B Vulvar itching

C Vulvar pain, described as stinging, burning, irritation,

raw sensation Subjective Data

A Include full medical, gynecologic, and sexual history,

using open- ended questions

1 Assess the patient for signs of depression, anxiety,

and sexual concerns

2 Review the medication list with the patient

Specifi cally ask about the types of medications that may contribute to low sexual desire:

3 Assess for medical conditions that contribute to

sexual dysfunction, which may include:

a Chronic diseases (cardiovascular disease,

diabe-tes, kidney or liver failure)

b Neurologic disorders

c Hormone imbalances

d Alcoholism

e Elicit drug use

f Evaluate for causes of pelvic pain: Vaginal

dry-ness, vaginal discharge, or vaginal infectious causes (such as STIs, yeast infections, or PID)

4 Evaluate for history of previous pelvic disorders or

surgery (fi broids, endometriosis, malignancy, uterine/

bladder prolapse, or episiotomy)

5 Evaluate for the degree of distress that this may

cause the patient

B Th e use of self- report screening tools is recommended

to identify women with low sexual desire Th ese tools may include:

1 Decreased Sexual Desire Screener

14 Gynecologic

a Found at www.obgynalliance.com/ fi les/ fsd/

DSDS_ Pocketcard.pdf

2 Brief Sexual Symptom Checklist for Women

a May be downloaded from www.researchgate net/ figure/ 277610474_ fig1_ Figure- 2- The- modified- Brief- Sexual- Symptom- Checklist- for- Women- BSSC- W

3 Female Sexual Function Index:

a Found at www.fsfi questionnaire.com

Physical Examination

A Vital signs: Check BP, pulse, and respirations

B Inspect

1 Th yroid for presence of nodules

2 Breasts for presence of nipple discharge if history

warrants

3 Skin for hirsutism, acne, alopecia, and truncal

obe-sity may indicate hyperandrogenism

C Palpate

1 Th yroid for presence of nodules

2 May palpate breasts for presence of nipple

dis-charge if history warrants

Pelvic Examination

A Inspect

1 Examine external genitalia for erythema, lesions,

atrophy, or unusual discharge

2 Inspect for vulvar dermatoses, such as lichen

scle-rosus or lichen planus Lichen sclescle-rosus may look like white skin discolorations or wrinkled patches of skin

Severe cases may have bleeding or ulcerated lesions

Lichen planus may look like purple- colored lesions or bumps with fl at tops Th in white lines or blisters may appear over the lesions

3 Inspect for pelvic fl oor prolapse and pelvic fl oor

muscle contraction

B Palpate external genitalia for presence of pain

C Speculum examination

1 Assess for atrophy (common in postmenopausal

women), pelvic fl oor muscle strength, masses, lapse, and deep pelvic pain

A Laboratory tests should be performed as indicated

by the history and physical examination for any medical

conditions that may contribute to low desire

B Pap smear, STI testing, wet prep

C Serum testing may include thyroid function tests and

prolactin levels

D Androgen levels and testosterone levels alone are

unreliable, unless you suspect a hyperandrogenic

condi-tion, as evidenced by hirsutism, acne, alopecia, and

trun-cal obesity

E Transvaginal ultrasound may be warranted if pelvic

pain upon examination

1 Set realistic goals for treatment

2 Empower women to take an active role in

treat-ment plan Encourage discussion about anatomy and sexual function, allowing the women to ask questions

as they are comfortable

3 Offi ce- based therapy may be useful for viders who wish to include this in their practice

one offi ce- based counseling model detailed as follows:

a Permission:  Women are given permission for

full discussion of the topic

b Limited information: Th e provider gives tional information on sexual function and sexual dysfunction in the form of handouts or videos

c Specifi c suggestion: Th e provider gives very specifi c advice tailored to each patient and her pre-senting issues

d Intensive therapy: Th e provider makes a referral for individual or couples therapy

B Patient teaching

1 Educate about normal anatomical and sexual functions

2 Encourage healthy lifestyle behaviors of diet,

exer-cise, avoiding tobacco, and minimizing stress

3 Educate patients about the use of vaginal

lubri-cants to assist with vaginal dryness or dyspareunia KY Jelly or Astroglide: Dose as needed with intercourse

C Pharmaceutical therapy is considered when

nonphar-macological interventions are not successful

1 Vaginal estrogen for the treatment of vaginal atrophy:

a Vagifem: 10 mcg, one tablet in vagina nightly

for 2 weeks, then twice a week for maintenance

b Estring: One ring, placed intravaginally every 3

months

c Premarin: 0.625 mg/ g: Insert 0.5 g/ d for 21

days on, 7 days off May adjust dose based upon patient response

d Estrace: 100 mcg/ g: Insert 2 to 4 g in vagina

nightly for 2 weeks, then gradually taper to half the

initial dose for 1 to 2 weeks, then a maintenance dose

of 1 g one to three times a week for maintenance

Taper or discontinue at 3- to 6- month intervals

3 Ospemifene

a Is a nonestrogen compound for treatment of

moderate to severe dyspareunia related to vaginal atrophy in postmenopausal females

b Dosage: 60 mg once per day

Follow- Up

A As determined by the history and physical

exami-nation fi ndings and diagnoses made Women placed on medications should follow up 1  month after initiating and have routine follow- up at 3- to 6- month intervals to determine if continuation of the medication is necessary

B Postmenopausal women with vaginal bleeding should

B May refer to pelvic fl oor therapist for treatment of

genitopelvic pain disorders, once other medical tions have been treated

Individual Considerations

A Use of opposing progestin is not necessary when using

lowest dose estrogens, though use of estrogen should be the lowest possible eff ective dose for the shortest duration

B Patients with a history of breast cancer: Although risk

is low, consult with the patient’s oncologist before ing vaginal estrogen

C If using ospemifene (Osphena), use opposing

pro-gestin in women with intact uterus Contraindicated in women with undiagnosed abnormal vaginal bleeding, history of venous thromboembolism, pulmonary embo-lism, breast cancer, and women of childbearing age

Resources American Association of Sexuality Educators, Counselors and Th erapists

1444 I Street, NW, Suite 700 Washington, DC 20005 (202) 449– 1099 e- mail: info@aasect.org www.AASECT.org International Society for the Study of Women’s Sexual Health

PO Box 1233 Lakeville, MN 55044 (218)- 461– 5115 e- mail: info@isswsh.org www.ISSWSH.org North American Menopause Society

5900 Landerbrook Drive Suite 390

Mayfi eld Heights, OH 44124 (440)- 442– 7550

e- mail: info@menopause.org Society for Sex Th erapy and Research

6311 W. Gross Point Rd Niles, IL 60714 (847)- 647– 8832 e- mail: info@sstarnet.org www.SSTARNET.org

Infertility

Rhonda Arthur

Defi nition

A Infertility is defi ned as the inability to conceive within

12 months of unprotected intercourse Many clinicians use a 6- month time frame if the woman is 35 years of age and older

B A woman who has never been pregnant or a man who

has never initiated a pregnancy is said to have “primary infertility.”

C If a previous pregnancy has been achieved and the

couple is unable to conceive a subsequent pregnancy, the term “secondary infertility” is applied

Incidence

A It is estimated that approximately 6.7 million women

have impaired ability to become pregnant or carry a baby

to term in the United States Pelvic infl ammatory ease (PID) is the leading cause of infertility in the world

dis-About 10% of infertility is unexplained

Pathogenesis Infertility may occur in the male (approximately 35%) or female (approximately 55%) Evaluate both partners for

Other Signs and Symptoms

A Dependent on the pathogenesis and history

Subjective Data

A Obtain a complete health history, including the following:

1 Age of both partners

2 General health of both partners

3 Complete pregnancy history of the female

a Number of pregnancies: Term and preterm

b Vaginal deliveries or cesarean sections

c Recurrent miscarriages, gestational age(s)

d Stillbirths

e Dilation and curettage (D&C) for abortions or

miscarriages

f Cerclage for incompetent cervix

4 Paternity history of the male

5 Length of infertility, including prior workup, if any

6 Coital history

a Frequency

b Timing and adequacy

c Use of lubricants; some may be spermicidal

d Postcoital habits: Douching or voiding

7 Adequacy of intercourse

a Penetration of the vagina

b Ejaculation by the male

14 Gynecologic

TABLE 14.2 Pathogenesis of Infertility

A Faulty sperm production A Advanced maternal age

1 Azoospermia from B Disorder of ovulation/ hypothalamic dysfunction

c Sertoli- cell- only syndrome 3 Polycystic ovary triad

e Retrograde ejaculation b Obesity

a Varicocele 4 Premature ovarian failure

b Small testicular size a Autoimmune

B Reproductive tract anomaly b Idiopathic

1 Blocked vas deferens c Cancer therapy

2 Varicocele 5 Luteal phase insuffi ciency

3 Congenital obstruction of epididymis 6 Prolactinoma

C Klinefelter’s syndrome C Ovarian factors

D Physical and chemical agents’ exposure 1 Cysts or tumor

2 Radiation D Tubal disorders/ damage/ blocked

2 Low serum testosterone 3 Postpartum infection

3 Pituitary tumors 4 Pelvic trauma (motor vehicle accident)

4 Hyperprolactinemia 5 Infl ammatory bowel disease

F Testicular infection 6 Endometriosis

G Injury to reproductive organs/ tract 7 Adhesions

H Nerve damage/ neurologic disease: Spinal cord injury E Uterine pathology

I Impotence/ erectile diffi culty: Performance anxiety 1 Congenital anomalies: Duplication

4 Malnutrition 1 Anatomic abnormalities (hood)

3 Hostile cervical mucus

4 Presence of sperm antibodies in the cervix

4 Date of last menstrual period (LMP)

C Obtain a complete gynecologic history including

E Review female and male reproductive tract infections

and treatments for past and present partners

F Review each individual’s habits

1 Smoking: How much, how often, how long

2 Drugs: How much, how often, how long for each drug

3 Alcohol: How much, how often, how long

4 Use of saunas or hot tubs

5 Exercise, including cycling

G Take a complete medication history, specifi cally review for

I Inquire about diethylstilbestrol (DES) exposure in

utero (for either partner)

J Review for symptoms of thyroid dysfunction

1 Weight gain or loss

Signs and Symptoms

A See the “Pathogenesis” section and information obtained in the “Subjective Data” section regarding past medical history

B History of not being able to get pregnant over the past

IUD, intrauterine device; PID, pelvic infl ammatory disease

TABLE 14.2 Pathogenesis of Infertility (continued)

14 Gynecologic

Physical Examination

Male

A Check temperature, pulse, respirations, and blood

pressure (BP) Obtain height, weight, and body mass index

(BMI)

B Inspect

1 Note general signs and appearance of

underandro-genization:  Decreased body hair, gynecomastia, and eunuchoid proportions

2 Test the patient’s visual fi eld for possible mass lesion

3 Examine the penis for hypospadias Observe

ure-thra for discharge

C Percuss: Check deep tendon refl exes (DTRs) for signs

E Rectal examination: Check prostate and seminal

vesi-cles for tenderness and other signs of infection

Valsalva’s maneuver performed while the patient stands helps to reveal small varicocele Varicocele feels like “a bag of worms” with bluish discoloration visible through the scrotum Approximately 23% to 30% of infertile males have a varicocele (usually present on the left side) No treatment is necessary if the semen anal- ysis is normal

2 Note general signs and appearance of polycystic

ovary syndrome (PCOS)

PCOS triad includes acne, obesity, and hirsutism

C Auscultate:  Abdomen for bowel sounds in all

quad-rants Auscultation of the abdomen should precede any

palpation or percussion due to the changes in intensity

and frequency of sounds after manipulation

D Palpate

1 Neck: Examine the thyroid

2 Abdomen: Note tenderness and masses

3 Back:  Check for costovertebral angle (CVA) tenderness

E Percuss: Check DTRs

F Pelvic examination

1 Inspect: Perform detailed external peritoneal

exam-ination for signs of infection; lesions; or anomalies of clitoris, labia, Skene’s gland, Bartholin’s gland, vulva, and perineum

2 Speculum examination

a Observe length of vagina, position and

charac-teristic of cervix, and any anomalies

b Sound the uterus and cervix for stenosis

Observe the characteristics of cervical mucus: Th in and watery or thick and cloudy, odor, or evidence

of infection

3 Bimanual examination:  Check uterine size,

con-sistency, contour, mobility, cervical motion ness (CMT), and adnexal masses

A fi xed, immobile uterus determined on bimanual examination indicates the presence of pelvic scarring resulting from conditions such as endometriosis and pelvic infl ammatory disease (PID)

4 Rectovaginal examination: Palpate uterosacral

liga-ments for pain and nodularity; evaluate masses and polyps of the rectum

Diagnostic Tests

A Male factor: Semen analysis

B Female (ovarian) factor

1 Basal body temperature (BBT)

2 Serum progesterone measured midway through luteal phase: Serum progesterone greater than 15 ng/ mL indicates ovulation

3 Urinary luteinizing hormone (LH) for surge

4 Follicle- stimulating hormone (FSH): A high FSH,

greater than 40 m IU/ mL, indicates ovarian failure

5 Th yroid- stimulating hormone (TSH)

6 Serum prolactin

When nipple discharge is present, check serum lactin and TSH to rule out hyperprolactinemia and hypothyroidism

1 Papanicolaou (Pap) smear with maturation index

2 Cultures for gonorrhea and chlamydia

3 Pregnancy test, if amenorrhea is present

4 Complete blood count (CBC), sedimentation rate

1 Semen analysis is the fi rst step in an infertility

workup Semen analysis should be performed in a reputable laboratory If the fi rst evaluation is abnor-mal, it should be repeated one time Normal semen analysis includes the following:

a Sperm count: Greater than 20 million/ mL

evalu-as well evalu-as guidance for the frequency and timing of intercourse

b Endometrial biopsy:  Sampling of the uterine

lining late in the luteal phase Th e test is uled 10  days after the BBT increase, or 2 to

sched-3 days before the onset of the next menses mal secretory endometrium and the absence of

feasible

c HSG (performed in radiology): Evaluates tubal

patency and rules out uterine anomalies Th e HSG should be scheduled for the interval between cessa-tion of menstrual fl ow and ovulation to avoid ret-rograde fl ow of menstrual tissue into the tubes and the abdominal cavity

d Laparoscopy:  Diagnostic if used as the fi nal

screening examination for infertility Performed by

a gynecologist, it is usually done in the fi rst 2 weeks

of the menstrual cycle to ensure that the patient

is not pregnant Direct visualization of the pelvic organs provides data about degree of adhesion for-mation, presence of endometriosis or fi broids, and the possibility of surgical repair of damaged tubes

B Patient teaching

1 Infertile couples often require extensive

counsel-ing, including grief counseling for failure to achieve pregnancy

2 Teach the patient to take BBT measurements See

Section III: Patient Teaching Guide for this chapter,

“Basal Body Temperature Measurement.”

C Pharmaceutical therapy

1 Treatment depends on causative factor(s)

2 Prescription medications must be supervised by

physician and/ or specialist because of possible plications such as ovarian hyperstimulation

Follow- Up

A Follow- up depends on causative factor(s)

Consultation/ Referral

A Consultation and referral are required for special

test-ing, surgery, and assisted reproductive therapy

B Immediate referral to a physician is necessary for

ovar-ian hyperstimulation

Individual Considerations

A Older adults

1 Advancing age increases the risk of age- related

infertility Women aged 35 years and older should be referred to a fertility specialist if unsuccessful in con-ceiving after 6 months

2 Women aged 40 years and older should be referred

as soon as possible for assisted reproductive therapy

Menopause

Rhonda Arthur

Defi nition

A Physiologic or natural menopause is the cessation

of menses for 12 consecutive months due to the loss

of ovarian follicular activity Natural or physiologic menopause is a retrospective diagnosis recognized 12 months after the fi nal menses Natural menopause is generally experienced in women between 45 and 55 years of age

B Natural menopause before the age of 40 years is

D Induced menopause is the abrupt cessation of menses

related to chemical or surgical interventions

E Perimenopause is caused by fl uctuations in ovarian

function in the years preceding menopause Th e average onset is usually in a woman’s 40s but may occur earlier

Due to fl uctuations in ovarian function, pregnancy may still occur and unintended pregnancy should be avoided

Perimenopausal symptoms often last several years, with the average duration being 5 years

Incidence

A By the year 2020, it is expected that the number of

women in the United States who are older than 51 years will exceed 50 million

▶

14 Gynecologic

Pathogenesis

A Physiologic menopause is due to failure of ovarian

follicular development and ovarian hormone depletion

negative feedback on the hypothalamic– pituitary

sys-tem with increasing follicle- stimulating hormone (FSH)

and luteinizing hormone (LH) When the ovaries cease

to produce estrogen, they become unable to respond

to FSH, resulting in the cessation of ovulation and

D Vasomotor symptoms such as hot fl ashes/ night sweats

E Intermenstrual or postcoital spotting/ bleeding should

be evaluated for pathologic causes

Subjective Data

A Determine onset, duration, and course of presenting

symptoms

B Obtain complete medical history, including

medica-tions, and assess for risk of osteoporosis, cardiovascular

disease, and breast and endometrial cancer

C Obtain complete gynecologic history, including

men-arche, interval, and duration of menstrual cycles, history

of dysmenorrhea, and pregnancy history Question the

patient regarding sexual history and contraceptives used

(condoms, pills, diaphragm, intrauterine devices [IUDs]),

frequency of method used

D What is the patient’s current menstrual pattern? Does

she think she is pregnant?

E Review associated symptoms (hot fl ashes, insomnia,

genitourinary symptoms), onset, timing, duration, and

impact on daily life

F Assess for mood swings and dysphoria

Physical Examination

A Check temperature, pulse, respirations, and blood

pressure

B Inspect:  Observe general overall appearance and

obtain height, weight, and BMI

C Auscultate

1 Heart

2 Lungs

3 Abdomen:  Auscultation of the abdomen should

precede any palpation or percussion due to the changes in intensity and frequency of sounds after manipulation

D Percuss the abdomen for organomegaly

E Palpate

1 Palpate thyroid gland

2 Perform clinical breast examination

3 Palpate groin for lymphadenopathy

4 Palpate the abdomen for masses

F Pelvic examination

1 Inspect:  Examine vulva for Bartholin’s gland

relaxation, and atrophy

2 Palpate: “Milk” the urethra for discharge

3 Speculum examination:  Inspect for cervicitis and

friability Evaluate vaginal discharge and bleeding for color, amount, and odor Perform cultures and Papanicolaou (Pap) test as indicated

4 Bimanual examination

a Check cervical motion tenderness (CMT);

evaluate the size, contour, mobility, and ness of the uterus An enlarged or irregular uterus requires additional evaluation

Over time, it is normal for the postmenopausal uterus

to decrease in size

b Palpate the adnexa for tenderness and masses.

Ovaries should not be palpable in postmenopausal women and require further evaluation if masses or ovaries are appreciated

5 Rectovaginal examination: Examine stool for

occult blood in women older than 50 years Diagnostic Tests

A Consider thyroid- stimulating hormone (TSH)

gonadotropin (HCG)

C Complete blood count (CBC) if excessive vaginal bleeding

D Obtain Pap smear as indicated

E Endometrial biopsy as indicated for intermenstrual

spotting or vaginal bleeding after menopause

irregular uterus

G Additional screening as indicated, such as

mam-mogram, hemoccult, cholesterol, and bone mineral density

H FSH greater than 40 international units (IU)/ L is

consistent with menopause; however, fl uctuations in FSH and 17– 2 estradiol (E2) may make use of these markers unreliable and are no longer recommended for determin-ing menopausal status

1 Discuss common symptoms of menopause

2 Provide education regarding healthy lifestyle changes:  Regular exercise, weight control, smoking cessation, limiting use of drugs and alcohol, and stress reduction

3 Encourage a healthy diet rich in vitamin D and

calcium Supplement diet with calcium ments: 1,000 mg/ d for women aged 19 to 50 years;

supple-1,200 mg/ d for women aged 50 years and older

a Vitamin D supplements: 600 IU/ d until the age

of 70 years and then 800 IU/ d for 71 years of age and older Consider vitamin D serum screening and, if defi cient, treat accordingly See “Vitamin D Defi ciency” section in Chapter 21

4 Encourage water- soluble vaginal lubricants as

needed for vaginal dryness See section on “Atrophic Vaginitis.”

5 Avoid warm environments, caff eine, alcohol, spicy

food, and emotional upset; these may trigger hot

fl ashes

6 Encourage sleep hygiene and adequate rest

7 Discuss the risks and benefi ts of hormone

replace-ment therapy (HRT)

for osteoporosis according to current osteoporosis guidelines

9 Assess and treat cardiac risk factors including hypertension and lipids as indicated

10 Give the patient the relevant teaching guide

See Section III: Patient Teaching Guide for this ter, “Menopause.”

C Pharmaceutical therapy

1 HRT

a All women should be counseled regarding the

risk, benefi ts, limitations, and potential increased risks of HRT Benefi ts of HRT include the reduc-tion of hot fl ashes, insomnia, night sweats, vag-inal dryness, mood swings, and depression

Although HRT does reduce the risk of bone loss and fracture, due to potential risks and eff ective alternative treatments for osteoporosis, it is not recommended for the treatment of osteoporo-sis (see “Osteoporosis/Kyphosis/Fracture” section

in Chapter 21) Risks of HRT include venous thromboembolism and breast cancer Long- term unopposed estrogen therapy (ET) increases the risk of endometrial cancer Potential areas of con-cern with the use of HRT include gallbladder disease and cardiovascular events Th e provider should carefully screen and educate the patient before initiating HRT

b Estrogen and progesterone are recommended

for treatment of moderate to severe vasomotor

symptoms and moderate to severe vulvar and inal atrophy symptoms For women with an intact uterus, progesterone is used with ET to reduce the risk of endometrial hyperplasia and cancer

vag-Postmenopausal women without an intact uterus generally are not prescribed progesterone and are treated with estrogen alone

c Oral HRT may be given either sequentially

or continuously Th e sequential regimen is given daily, with progesterone given on days 1 to 12 of the month It is common to have withdrawal bleed with this regimen An alternative to this is the con-tinuous regimen in which both estrogen and pro-gesterone are taken daily

2 Transdermal estrogen

3 Transvaginal estrogen (see Tables 14.3– 14.5)

4 Absolute contraindications to use of ET also apply

to use of oral and topical estrogen (breast cancer, active liver disease, and/ or history of recent thrombo-embolic event) Vaginal estrogen creams are system-ically absorbed As with use of oral and transdermal estrogen, a progestin must be administered to women who have an intact uterus, secondary to the risk of endometrial hyperplasia or cancer

5 Absolute contraindications to ET

a Acute liver disease

b Cerebral vascular or coronary artery disease,

myocardial infarction (MI), or stroke

c History of or active thrombophlebitis or

throm-boembolic disorders

d History of uterine or ovarian cancer

e Known or suspected cancer of the breast

f Known or suspected estrogen- dependent neoplasm

7 Absolute contraindications to progesterone therapy

a Active thrombophlebitis or thromboembolic

disorders

b Acute liver disease

c Known or suspected cancer of the breast

d Pregnancy

e Undiagnosed, abnormal vaginal bleeding

Educate the patient to notify the care provider if sual vaginal bleeding, calf pain, chest pain, shortness

unu-of breath, hemoptysis, severe headaches, visual turbances, breast pain, abdominal pain, or jaundice occur while being prescribed HRT

D Nonhormonal pharmacological therapy for

vasomo-tor symptoms

1 Antidepressants

a Fluoxetine (Prozac) 20 mg/ d

▶

14 Gynecologic

TABLE 14.3 Hormone Replacement Therapy

Estrogen Sequential or Continuous Combined

Progestin Only for Sequential Regimen

Amen Medroxyprogesterone 5– 10 mg added to estrogen the fi rst

10– 14 days of the month Cycrin Medroxyprogesterone 5– 10 mg added to estrogen the fi rst

10– 14 days of the month Provera Medroxyprogesterone 5– 10 mg added to estrogen the fi rst

10– 14 days of the month Prometrium Micronized progesterone 100– 200 mg added to estrogen the

fi rst 10– 14 days of the month Progestin Only for Continuous Combined Regimen

Combination Packet for Continuous Combined Regimen

Prempro 0.625 mg conjugated equine estrogen

and 2.5 mg medroxyprogesterone

1 tablet orally each day Activella 1 mg 17- beta estradiol and 0.5 mg

norethindrone

1 tablet orally each day

FemHrt 5 mcg ethinyl estradiol and 1 mg

norethindrone

1 tablet orally each day

See complete prescribing reference or package insert for dosing, titration, contraindications, and side effects

TABLE 14.4 Transdermal Replacement Therapy

Transdermal patch Climara Estradiol 0.25 mg/ d–0.0375 mg/ d

0.05 mg/ d 0.06 mg/ d 0.075 mg/ d Apply one patch weekly (lower abdomen or upper buttocks)

Transdermal patch Combipatch Estradiol 0.05 mg and

noreth-Gel- Pump Elestrin Estradiol 0.06% gel, one pump daily to clean dry skin of

upper arm Gel- Pump Estrogel Estradiol 0.75 mg/ 1.25 g gel, one pump daily to clean dry

skin of upper arm Spray Evamist Estradiol 1.53 mg/ spray, one spray daily to inside of arm

See complete prescribing reference or package insert for dosing, titration, contraindications, and side effects

Pap Smear Screening Guidelines and Interpretation

b Venlafaxine (Eff exor) 37.5 to 75 mg/ d

c Paroxetine (Paxil) 12.5 to 25 mg/ d

2 Anticonvulsant

a Gabapentin (Neurontin) 300 mg/ d and titrate

to three or four a day

3 Antihypertensive

a Clonidine 0.05 to 0.1 mg/ twice a day For nonhormonal pharmacological therapies, review prescribing literature for side eff ects, titrations, and discontinuation regimens

E Nonprescription remedies/ herbals

1 Many nonprescription remedies are currently available for the treatment of menopausal symp-toms Th ese remedies include isofl avones (soy and red clover), black cohosh, dong quai, evening prim-rose oil (EPO), ginseng, licorice, and vitamin E and vitamin C

2 Th e provider should review with the patient the lack of standardization and evidence regarding the safety and effi cacy of these products Currently, results

of research have been insuffi cient to support or refute the use of these remedies for the treatment of meno-pausal symptoms

Follow- Up

A Follow up for 3 to 6  months to assess a response

to treatment, and then yearly for physical tion, Papanicolaou (Pap) smear, and lipid panel as indicated

B Consider discontinuation of HRT in 5 years based on

patient response and risks and benefi ts

In the United States, approximately 13,000 new cases

of cervical cancer will be diagnosed annually Of these cases, approximately 4,120 deaths will occur Cervical cancer is the seventh most common cancer in women

deaths over the last 30 years due to the use of Pap smear screening

Th e following are risk factors for development of vical cancer:

A Early age at fi rst intercourse: Younger than 18 years

B Multiple sexual partners: More than three in a lifetime

H Male partner with a history of multiple partners or

sexually transmitted infections (STIs)

I History of STI, especially human papillomavirus (HPV)

Sexually transmitted agents, particularly the HPV strains 16, 18, 31, 33, 39, and 42, are strongly asso- ciated with the development of cervical cancer HPV DNA is present in 93% of cervical cancer and precur- sor lesions

TABLE 14.5 Transvaginal Replacement Therapy

Cream Estrace Micronized 17- beta

estradiol

0.1 mg/ g, one- half (2 g) to one (4 g) applicator intravaginally at bedtime every night for 1– 2 weeks When vaginal mucosa is restored, maintenance dose is one- quarter applicator (1 g) one to three times weekly in a cyclic regimen.

Premarin Conjugated equine

estrogen

0.625 mg/ g, use 0.5- to 1.0- g applicator inserted intravaginally

at bedtime every night for 1– 2 weeks, then every other night for 1– 2 weeks, then as needed

Ring Estring Micronized 17- beta

estradiol

7.5 mg/ 24 hr; insert new ring every 90 days Femring Estradiol acetate 0.05– 0.1 mg/ d; insert new ring every 90 days Vaginal tablet Vagifem Estradiol acetate 25 mcg once daily for 2 weeks then twice weekly

See complete prescribing reference or package insert for dosing, titration, contraindications, and side effects

IUD, intrauterine device

14 Gynecologic

J Diethylstilbestrol (DES) exposure in utero

K Cervical dysplasia: Th e risk of carcinoma is 100 times

greater in women with dysplasia than in those with a

nor-mal cervix

Th e Pap smear should include sampling from both the ectocervix and the endocervix to be considered “adequate

for interpretation.” Th e ectocervix is the cervical

por-tion extending outward from the external cervical os Th e

endocervix extends upward from the external os to the

internal os, where the cervical epithelium meets the

uter-ine endometrium

Cervical epithelium is composed of squamous and columnar cells Squamous epithelium, appearing smooth

and pink, lines the vagina and continues upward to cover

variable amounts of the ectocervix Columnar

epithe-lium, darker red and more granular in appearance, lines

the endometrium and continues downward to the

cer-vix, lining the endocervical canal Th e boundary between

squamous and columnar epithelium is called the

squa-mocolumnar junction (or transformation zone) and may

occur anywhere on the ectocervix or endocervix

Th e squamocolumnar junction may regress at various times as a result of hormonal variation, particularly with

sexual activity and during pregnancy, through processes

known as epidermidalization and squamous metaplasia

Epidermidalization is an upward growth of squamous

cells that replace columnar cells Squamous metaplasia is

the diff erentiation of columnar cells into squamous cells

Th e area between the original and new squamocolumnar

junction is called the transformation zone When

colum-nar epithelium is visible on the ectocervix, appearing as a

granular, red area, it is referred to as eversion, ectropion,

or ectopy Th is is often seen in pregnancy or with oral

contraceptive use

Cervical cancer is a progressive disease with a ber of histologically defi nable stages Invasive cancer of

num-the cervix and its precursors are detectable by cytology

before becoming symptomatic and before gross

clini-cal signs appear When symptoms are present, they

usu-ally include (in order of frequency) postcoital spotting;

intermenstrual bleeding, especially after exertion; and

increased menstrual bleeding Patients with invasive

can-cer may experience serosanguineous or yellowish vaginal

discharge, which may be foul smelling and intermixed

with blood

Advanced disease may cause urinary or rectal toms, including bleeding On speculum examination,

symp-advanced lesions appear as necrotic ulcers; in invasive

dis-ease they may extend upward or protrude into the vagina

See Section II: Procedures, “Pap Smear and Maturation Index Procedure.”

Bethesda System

Th e 2001 BethesdaSystem (classifi cation system used

to interpret cytologic fi ndings) was updated in 2014 It

includes the following information:

A Specimen type

1 Conventional versus liquid- based preparation

ver-sus other

B Adequacy of the specimen

1 Satisfactory for evaluation

2 Presence or absence of endocervical or

transforma-tional zone components

3 Quality indicators such as obscuring blood or infl ammation

4 Unsatisfactory for evaluation and specifi c reason

C General categorization

1 Negative for intraepithelial lesion or malignancy

2 Other, such as endometrial cells in women older

than 45 years

3 Epithelial cell abnormality:  See “Interpretation/

result” that follows

If an infection is indicated as a Pap smear fi nding, evaluate the patient and treat her accordingly Pap smears are not diagnostic of vaginal or cervical infec- tion Institute therapy for infections confi rmed through the use of wet prep and/ or cultures as guided by cytologic reading For example, if Candida is identifi ed on Pap smear results, evaluate the patient in the offi ce, confi rm

fi nding, and treat the patient with appropriate fungal therapy

D Interpretation/ result

Negative for intraepithelial lesion or malignancy (optional

to report)

1 Non- neoplastic cellular variations

2 Reactive cellular changes associated with

c Shift in fl ora suggestive bacterial vaginosis (BV)

d Cellular changes consistent with herpes

E Epithelial cell abnormalities

1 Squamous cell abnormalities

a Atypical squamous cells of undetermined

sig-nifi cance (ASCUS): Indicates some abnormality but the cause is unclear (infection common)

b Atypical squamous cells— high grade

squa-mous intraepithelial lesion

c Low- grade squamous intraepithelial lesion

(LSIL): Indicates human papillomavirus (HPV), mild dysplasia, or cervical intraepithe-lial neoplasia (CIN) I

d High- grade squamous intraepithelial lesions (HSILs):  Moderate and severe dyspla-sia, carcinoma in situ or CIN II, and CIN III

e Squamous cell carcinoma

▶

Pap Smear Screening Guidelines and Interpretation

2 Glandular cell

a Atypical

i Endocervical cells (not otherwise

spec-ify [NOS] or specspec-ify in comments)

comments)

comments)

b Atypical

i Endocervical cells favor neoplastic

ii Glandular cells favor neoplastic

c Endocervical adenocarcinoma in situ

d Adenocarcinoma

i Endocervical

ii Endometrial iii Extrauterine

iv NOS

F Other malignant neoplasms: specify

G Adjunctive testing

H Computer- assisted interpretation of cervical pathology

I Educational notes and comments appended to

cytol-ogy report (optional)

Initial Management of Abnormal Pap Smears

A ASCUS or LSIL in women aged 21 to 24 years

1 Repeat cytology in 12  months for the next

2  years, with colposcopy after 1  year for HSIL and colposcopy after 2  years if ASCUS or LSIL remains

2 HPV: Not recommended, but if performed:

a HPV negative, continue routine screen with

Pap test in 3 years

b HPV positive, annual Pap smear for 2 years

with colposcopy after 1 year if HSIL continues and after 2 years if ASCUS or LSIL continues

B ASC- H is managed with colposcopy

C LSIL

cotesting in 1 year or colposcopy

2 LSIL with positive or no HPV test is managed

with colposcopy

3 Pregnant women with LSIL can be managed with

colposcopy or can defer colposcopy until 6 weeks postpartum

D HSIL management in women includes either

imme-diate loop excision or colposcopy

E Atypical glandular cells (AGC) management for

all subcategories except atypical endometrial cells includes colposcopy For women aged 35  years and older with risk of endometrial neoplasm, endometrial sampling is also indicated

1 Atypical endometrial cell management includes endometrial and endocervical sampling

F Unsatisfactory cytology

1 If HPV unknown or HPV negative, repeat

cytol-ogy in 2 to 4 months

2 If HPV positive, either repeat cytology in 2 to

4 months or perform colposcopy

3 If there are two consecutive unsatisfactory

cytol-ogy tests, then colposcopy is indicated

G Cytology negative but absent or insuffi cient vical/ transitional zone component

1 Aged 21 to 29 or 30  years and older with HPV

negative, conduct routine screening cytology in

3 years

2 Aged 30 years and older and HPV unknown, HPV

testing is preferred

3 Aged 30 years and older and HPV positive,

con-duct cytology + HPV testing in 1 year or immediate genotyping for HPV

4 See and download ASCCP algorithms* for

com-plete management options at www.asccp.org

Th e American Society for Colposcopy and Cervical Pathology (ASCCP) has a mobile device appli- cation Look for the mobile application ASCCP Abnormal Cervical Cancer Screening Guidelines on iTunes

Recommendations According to the American Cancer Society (ACS), the U.S Preventative Task Force, ASCCP, and the American College of Obstetricians and Gynecologists guidelines, all women should begin cervical cancer screening at the age of 21  years Women younger than 21  years should not be screened regardless of the age of sexual initiation

Screening should be performed every 3 years No woman should be screened annually Highlights of the recom-mendations include:

A Begin screening at the age of 21 years

B Women from ages 21 to 29 years should have

conven-tional or liquid- based cytology every 3 years, and no HPV testing should be performed

C Women from ages 30 to 65 years should have

conven-tional or liquid- based cytology every 3 years or, to extend testing time, use conventional or liquid- based cytology plus HPV co- test every 5 years HPV co- testing should not be used in women younger than 30 years

D Stop screening at age older than 65 years with adequate

screening history Negative history includes having three consecutive negative cytology results or two consecutive tests with cotesting results in the past 5 years for the patient

E Continued regular screening is recommended for women who have had a history of CIN II, CIN III, or adenocarcinoma

F Posthysterectomy:  Stop screening for total ectomy However, if the patient had a history of high- grade lesions before surgery, then cytology screening every

hyster-3 years for the next 20 years is recommended

G HPV vaccination screen according to age- specifi c recommendation

H Women who have a high- risk medical history

(immu-nocompromised, HIV positive, DES-exposed in utero,

* Th e Journal of Lower Genital Tract Disease, Volume 17, Number 5, with

the permission of ASCCP © , the American Society for Colposcopy and Cervical Pathology, 2013.

14 Gynecologic

or a history of cervical cancer) are not included in the

updated routine guidelines

Th e Advisory Committee on Immunization practices recommends routine vaccination of females and males

aged 11 to 12 years with three doses of quadrivalent HPV

vaccine and states the series can be started as young as

9 years of age Catch- up vaccination is recommended for

adolescents and young adults aged 13 to 26 years

Patient education regarding the prevention of cal cancer by avoiding exposure to HPV should include

cervi-reduction or elimination of high- risk activities Th ese

high- risk activities include having sexual intercourse at an

early age, having multiple sexual partners, having partners

with multiple partners, and having sex with

uncircum-cised males Use of condoms can reduce the risk of HPV

as well as other STIs Smoking cessation can also reduce

the risk of cervical cancer Identifi cation and treatment of

precancerous lesions can reduce the risk of invasive

cer-vical cancer, so screening according to ACS guidelines

should be encouraged

Treatment Modalities

Treatment is instituted based on the severity of the

lesion and the presence of pathology within the

colum-nar epithelium of the endocervix Treatment options

include

A Observation and repeat cytology

B Cryotherapy

C Loop excision of the transformation zone

D Laser of the transformation zone

E Cold- knife conization

F Observation and repeat cytology

Pelvic Infl ammatory Disease

Rhonda Arthur

Defi nition

A Pelvic infl ammatory disease (PID) is an infl

amma-tion caused by an infecamma-tion of the upper genital tract Th is

infl ammation can involve the uterine endometrium

(endo-metritis), fallopian tubes (salpingitis), ovaries (oophoritis),

broad ligament or uterine serosa (parametritis), and the

pelvic vascular system or pelvic connective tissue

Incidence

A Annual incidence is diffi cult to obtain due to diffi

-culty in defi nitive diagnosis and reporting

B PID is the leading cause of infertility in the world

Pathogenesis

A PID is caused by organisms that ascend from the

vagina and cervix into the uterus Menses facilitates

gon-ococcal invasion of the upper genital tract as the luteal

phase stimulates gonococcal growth and the cervical

mucus barrier is removed Infection and infl ammation

spread throughout the endometrium to the fallopian

tubes From there, they extend to the ovaries and

perito-neal cavity

B Th e most common organisms cultured from patients with PID are Chlamydia trachomatis , Neisseria gonor- rhoeae , Mycoplasma hominis , Ureaplasma urealyticum , Bacteroides, Peptostreptococcus , Escherichia coli , and some

endogenous aerobes and anaerobes

C Th e incubation period varies with the infective organism

Predisposing Factors

A Age: Rates of PID are higher for women at younger

ages It is highest in the younger than 30- year- old age group (70% incidence under the age of 25 years) Teens are particularly susceptible because they have an imma-ture immune system and larger zones of cervical ectopy with thinner cervical mucus

B Sexual activity: Women with multiple sexual partners

are three times more likely to develop PID, when pared to women with only one partner

C Intrauterine devices (IUDs): IUDs can lead to an

iat-rogenic development of PID and can promote the spread

of vaginal or cervical organisms into the uterus by means

of the IUD string

D History of PID

E Menstruation: Supports the development and spread

of PID Women who are not currently menstruating have

a decreased risk

F History of invasive procedures: Th ese procedures may result in iatrogenic PID PID is usually seen within 4 weeks of the procedure (dilatation and curettage [D&C], IUD insertion, hysterosalpingogram [HSG], and vacuum curettage abortion)

G Th ere is an increased incidence of PID in African Americans and non- White women and women in lower socioeconomic groups

C Increased vaginal discharge

D Nausea and vomiting

E Low back pain

Other Signs and Symptoms

A Asymptomatic; vague and nonspecifi c symptoms

B Minimal to severe pelvic pain

C Right upper quadrant pain (25%)

D Abnormal vaginal bleeding

Subjective Data

A Determine onset, duration, and course of presenting

symptoms

B Review the character of vaginal discharge (if any);

history of recent dysmenorrhea and/ or dyspareunia; any intestinal or bladder symptoms

C Question the patient regarding sexual history:

Current number of sexual partners; current or most recent sexual activity; and contraceptive used (condoms, pills, diaphragm, IUD) and frequency of method used

Pelvic Infl

D Question the patient as to whether her current sexual

partner has experienced any symptoms

E What is the patient’s current menstrual pattern? Does

she think she is pregnant? When did the pain begin in relation to her cycle?

F Review prior pelvic or abdominal surgeries and

proce-dures (HSG, abortion) and when they were done

G Review the history and quality of pain: How long,

bilateral or unilateral, what makes it better, and what makes it worse (intercourse, Valsalva’s maneuver with bowel movement, activity)

Physical Examination

A Check temperature, pulse, respirations, and blood pressure

B Inspect:  Observe general overall appearance for

dis-comfort before, during, and after examination

C Auscultate abdomen for bowel sounds in all

quad-rants Auscultation of the abdomen should precede any palpation or percussion due to the changes in intensity and frequency of sounds after manipulation

D Percuss the abdomen for organomegaly

E Palpate

1 Palpate the groin for lymphadenopathy

2 Palpate the abdomen for masses

3 Palpate the levator ani muscle left and right, the

urethra, and the trigone of the bladder

4 Perform rebound, involuntary guarding, and jar

tests Th e jar test is performed by intentionally ting or jarring the examination table and watching for a pain response Pelvic discomfort is exacerbated

hit-by the Valsalva maneuver, intercourse, or movement

Abdominal or pelvic pain with PID is usually eral About 25% of patients complain of right upper quadrant (RUQ) pain; the pain usually occurs within

bilat-7 to 10 days of menses, remains continuously, and is most severe in the lower quadrants

F Pelvic examination

1 Inspect:  Examine the vulva for Bartholin’s gland

enlargement, fi ssures, condyloma, herpes, and pelvic relaxation

2 Palpate: “Milk” the urethra for discharge

3 Speculum examination:  Inspect for cervicitis

and friability Evaluate vaginal discharge and ing for color, amount, and odor Lower abdomi-nal or pelvic pain is the most common symptom of PID and typically is moderate to severe; however, many women may have subtle or mild symptoms that are not readily recognizable as PID, includ-ing abnormal bleeding, dyspareunia, or vaginal discharge

G Bimanual examination

1 Check cervical motion tenderness (CMT);

evalu-ate the size, contour, mobility, and tenderness of the uterus

2 Palpate the adnexa for tenderness and masses

Classic PID presentation is lower abdominal and adnexal tenderness and CMT (chandelier sign) Th e pelvic area may feel hot

H Rectovaginal examination: Assess for adnexal

thicken-ing and masses

Diagnostic Tests

A Complete blood count (CBC) with diff erential; white

blood cell (WBC) greater than 10,500 cell/ mm 3

B Sedimentation rate or C- reactive protein (CRP)

C Quantitative beta human chorionic gonadotropin (HCG)

D Rapid plasma reagin (RPR), hepatitis B surface

anti-gen, and HIV if indicated

E Cultures for gonorrhea and chlamydia

I Diagnostic criteria (DC) for clinical diagnosis of PID

1 Minimal criteria:  Empiric treatment for PID should be initiated in sexually active women at risk for STDs if they are experiencing one of the following with no other cause identifi ed:

a Lower abdominal tenderness

b Adnexal tenderness

c CMT

2 Additional routine criteria (one or more of the

fol-lowing support diagnosis of PID)

a Oral temperature greater than 101°F

b Abnormal cervical or vaginal discharge

c Elevated erythrocyte sedimentation rate (greater than 15 mm/ hr)

d Elevated C- reactive protein

e Laboratory documentation of cervical infection

with N. gonorrhoeae or C. trachomatis

3 Elaborate criteria for diagnosing PID

a Histopathologic evidence of endometritis on

2 Irritable bowel syndrome

3 Ulcerative colitis, Crohn’s disease

2 Pelvic fl oor myalgia

3 Spinal injuries or degenerative disease

E Neurologic factor: Nerve entrapment syndrome

Plan

A General interventions

1 A low threshold is needed for diagnosis of PID

because of the risk of damage to reproductive health

Early treatment with the use of antibiotics of an upper genital tract infection is imperative Other causes of lower abdominal pain, such as irritable bowel syndrome and endometriosis, are not likely

to be impaired by empiric antibiotic therapy Th e risk of ectopic pregnancy is 6 to 10 times greater with women with PID compared with uninfected women

2 Antibiotic therapy should be instituted promptly,

based on clinical diagnosis without awaiting culture

results, to minimize the risk of progression of the infection and risk of transmission of the organisms to other sexual partners

3 If a woman with an IUD in place is diagnosed

with PID, the IUD does not need to be removed

treat-ment If there is no improvement in 48 to 72 hours, the health care provider should consider removing the IUD

closely and reevaluated within 3  days of ing antibiotic therapy A  decrease in pelvic ten-derness should be observed within 3 to 5  days of initiation of therapy; if not, additional evaluation is warranted

B Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Pelvic Infl ammatory Disease.”

1 Male sexual partners (and all partners) of patients

with PID must be examined, cultured when possible, and treated empirically for presumptive gonorrheal and chlamydial infection

2 Women who do not use any contraception are at

the greatest risk Transmission of sexually ted infections (STIs) can be minimized with eff ec-tive use of barrier contraceptives Spermicides prevent

of nonoxynol- 9 is protective against N.  gonorrhoeae, Treponema palladium, Trichomonas, herpes simplex virus (HSV), and Candida

3 Oral contraceptive pills are associated with an increase in chlamydia detection in the cervix, and they protect against symptomatic PID

C Pharmaceutical therapy (see Table 14.6)

▶

TABLE 14.6 Centers for Disease Control and Prevention Recommendations for Treating PID

Regimen A a

Cefotetan 2 g IV every 12 hours or cefoxitin 2 g plus

doxy-cycline 100 mg IV or orally every 12 hours This regimen is continued for at least 48 hours after clinical

improvement and followed by doxycycline 100 mg orally twice daily to complete 14- day total course.

Regimen B a

Clindamycin 900 mg IV every 8 hours (15– 40 mg/ kg/ d)

Plus

Gentamicin, loading dose 2.0 mg/ kg IV, followed by

main-tenance dose 1.5 mg/ kg IV every 8 hours Single daily dosing may be substituted.

This regimen is continued for at least 48 hours after

sig-nifi cant clinical improvement is demonstrated, and it

is followed by doxycycline 100 mg orally twice daily to complete a 14- day total course Alternatively, clindamy- cin 600 mg orally three times daily may be given to com- plete a 14- day total course.

Regimen A

Ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg

orally twice a day for 14 days

With or Without

Metronidazole 500 mg orally twice daily for 14 days

Or

Cefoxitin 2 g IM in a single dose and probenecid, 1 g orally

admin-istered concurrently in a single dose plus doxycycline 100 mg orally twice a day for 14 days with or without metronidazole 500

mg orally twice a day for 14 days

Or

Other parenteral third-generation cephalosporin (e.g., ceftizoxime or

cefotaxime) plus doxycycline 100 mg orally twice a day for 14 days with or without metronidazole 500 mg orally twice a day for 14 days

Note: For women or their partners who cannot tolerate doxycycline or tetracycline, erythromycin 500 mg orally four times daily may be used for 10 to

14 days

a When tubo- C is present, many clinicians use clindamycin because it provides more effective anaerobic coverage than doxycycline

IM, intramuscular; IV, intravenous; PID, pelvic infl ammatory disease